Jeffrey Bettinger, MD, FACEP, founder and managing member of consulting firm Bettinger, Stimler & Associates, explains how physicians should interpret this scenario when it arises.
“An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years,” according to the Centers for Medicare and Medicaid Services Evaluation and Management Services Guide.
“In my option, care in the ED is a service. Later on in the office, the physician would have to consider that patient an established patient, even though the ED codes and office codes would not be in the same CPT series,” says Dr. Bettinger.
The ED code series does not distinguish between new and established patients. “Even if you see a patient over and over again in the ED, the encounter will use the same type of code,” says Dr. Bettinger. But, if patients visit their ED physician in a clinic or office, they become established patients. From then on, the encounters become subsequent.
This situation will usually only arise for physicians who see patients when they are on-call for the ED.
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