How Often Are Established Patients Asked To Verify Their Necessary Data?

New vs. Established Patients: Who's New to You?

Billing for new patients requires three key elements and a thorough knowledge of the rules.

A persistent business organisation when reporting evaluation and management (E/M) services is determining whether a an individual is a new patient to the practice or already established. New patient codes carry college relative value units (RVUs), and for that reason are consistently under the watchful center of payers, who are quick to deny unsubstantiated claims. Here are some guidelines that will ensure your E/M coding holds upwardly to claims review.

Be Sure New vs. Established Applies

Not all Eastward/Yard codes fall nether the new vs. established categories. For example, in the emergency department (ED), the patient is e'er new and the provider is e'er expected to document the patient'southward history in the medical record.

In the office setting, patients see their provider routinely. The provider knows (or tin can quickly obtain from the medical tape) the patient's history to manage their chronic conditions, as well as make medical decisions on new problems.

A provider seeing a patient for the first time may non accept the benefit of knowing the patient'southward history. Even if the provider can access the patient's medical record, they volition probably inquire more questions.

Who Is a New Patient?

The definition of a "new" patient is given in the CPT® lawmaking book:

A new patient is one who has not received any professional person services from the doctor/qualified health care professional or another doctor/qualified wellness care professional person of the exact same specialty and subspecialty who belongs to the aforementioned grouping practice, inside the past three years.

In addition to this definition, the Centers for Medicare & Medicaid Services (CMS) adds in Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7):

An interpretation of a diagnostic test, reading an 10-ray or EKG etc., in the absence of an E/M service or other contiguous service with the patient does not affect the designation of a new patient.

Let'due south break downward the three key components that make up the new patient definition:

Professional Service: When physician coders see this, we automatically think of modifier 26 Professional services. This leads us to recall that if the provider bills a claim for radiology or labs, and sees the patient confront to face up, an established patient office visit must be billed. This is not true, per the same CMS guidance. If the provider has never seen the patient face to confront, a new patient lawmaking should be billed.

Case: A patient presents to the ED with chest pain. The ED doctor orders an electrocardiogram (EKG), which is interpreted by the cardiologist on call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; estimation and report simply. The patient is sent home and asked to follow up with the cardiologist next week for coronary artery disease. At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, simply did not encounter the patient face up to face.

Three-year rule: The general rule to make up one's mind if a patient is new" is that a previous, face-to-face service (if any) must accept occurred at to the lowest degree three years from the date of service. Some payers may have different guidelines, such every bit using the month of their previous visit, instead of the day.

Example: A patient is seen on Nov. 1, 2014. He moves away, only returns to run across the provider on November. two, 2017. Because it has been three years since the date of service, the provider tin bill a new patient E/M code.

Different specialty/subspecialty within the same grouping: This area causes the most confusion. For Medicare patients, you lot can use the National Provider Identifier (NPI) registry to see what specialty the physician's taxonomy is registered under. For payers, this usually is determined by the mode the provider was credentialed.

Those who are part of the credentialing procedure must understand how important information technology is to become the provider enrolled with the payer correctly. Denials will ensue if this is not done correctly.

New to Whom?

Problems begin when doctors switch practices, send patients to mid-levels, and cross-cover for each other. Hither are some examples of these situations:

If a doctor changes practices and takes his patients with him, the provider may desire to bill the patient as new based on the new tax ID. This is incorrect. The tax ID does not thing. The provider has already seen these patients and has established a history. He cannot beak a new patient code but because he'due south billing in a different grouping.
If a doctor of medicine (Medico) or dr. of osteopathy sends a patient to a mid-level provider (i.e., nurse practitioner (NP) or physician assistant (PA)) and the visit does not fall under incident-to, the NP or PA could nib a new patient code if they are a unlike specialty with different taxonomy codes. If the MD is a family practice provider and the NP sees hematology patients, for example, the specialty is different and a new patient code tin can be billed. But if the NP is also considered family do, it would not be appropriate to bill a new patient code.
If one provider is covering for another, the roofing provider must bill the same code category that the "regular" provider would have billed, even if they are a dissimilar specialty. For case, a patient'due south regular dr. is on vacation, so she sees the internal medicine provider who is covering for the family practice doctor. The internist must bill an established patient code considering that is what the family practice doctor would have billed.

Know the Exceptions

There are some exceptions to the rules. For instance, some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient lawmaking, even if they have seen the patient for years prior to her condign pregnant. Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.

Know When to Entreatment

If a claim is denied, look at the medical tape to see if the patient has been seen in the past 3 years by your group. If and then, check to see if the patient was seen by the aforementioned provider or a provider of the same specialty. Confirm your findings past checking the NPI website to see if the providers are registered with the same taxonomy ID. If it'southward a commercial insurance plan, check with the credentialing department, or call the payer, to meet how the provider is registered. If your enquiry doesn't substantiate the denial, send an appeal.

Meet also "Navigate the New vs. Established Patient Decision Tree."

Resource
Medicare Claims Processing Transmission, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.seven)

Author
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Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, is coding team leader at MedKoder in Hannibal, Mo. She has more than 15 years of experience in multiple areas of healthcare including auditing and compliance. Cox has been certified since 2002 and is treasurer of the Quincy, Ill./Hannibal, Mo., local chapter. She is the Region 5 AAPC National Advisory Lath representative.