Service Codes & New Vs. Established Patient Coding
There are two questions to this discussion; answer both questions.
- Place of service codes are required in box 24b of the CMS 1500 claim form. What place of service surprises you the most when you think that CPT services and procedures are done there and why? Give an example of a claim where this would be important to support your why answer. When you respond to your fellow students’ posts, do you agree with their examples and why or why not?
- Take a look at office visit codes for new patients 99201- 99205 and established visits 99211-99215. The new patient visit codes are reimbursed at a higher rate than the established. For example, consider the following codes and fees.
New Patient Office Visit Code | Fee | Established Patient Office Visit Code | Fee |
99201 | $50 | 99211 | $40 |
99202 | $60 | 99212 | $50 |
99203 | $ 70 | 99213 | $60 |
99204 | $80 | 99214 | $70 |
99205 | $90 | 99215 | $80 |
Why do you think new patient codes get higher reimbursement than established patient codes (for example a 99202 office visit codes reimburses higher than its counterpart 99212)?
Do you agree with your fellow students’ posts? Why or why not?
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Expert Solution Preview
Introduction: Place of service codes are required in box 24b of the CMS 1500 claim form. Similarly, there are separate office visit codes for new and established patients, and the new patient visit codes are reimbursed at higher rates than the established ones. In this discussion, we will explore the surprising places of service and the reasons behind the difference in reimbursement rates for new and established patient visit codes.
1) The place of service that surprises me the most when I think about the CPT services and procedures performed there is the “home.” Home-based care is becoming increasingly popular, especially for elderly or disabled patients who have difficulties traveling to a medical facility. In-home care includes services such as wound care, physical therapy, and medical equipment usage training. In a claim where a home visit is made, the place of service would be a code 12 (Home). This code is essential as it helps in determining the appropriate reimbursement level for the visit and identifying the services provided. I agree that in-home care is an essential aspect of healthcare, and it is vital to have proper coding to ensure proper reimbursement for the services provided.
2) The reason for higher reimbursement for new patient codes than established patient codes is two-fold: First, the first patient visit is usually more complicated than the follow-up visits, and the physician performs a comprehensive examination and medical history. Second, there is an increased burden for the physician to establish a new patient-physician relationship. Due to these factors, the reimbursement rates for new patient visit codes are higher than those for established patient codes. I agree with my fellow students’ posts, as their reasoning aligns with the commonly accepted payment methodologies in healthcare.
