# New vs Established-Subspecialty issue



## MATHEODO (Apr 16, 2014)

Here is the situation.   
Two ortho surgeons in a multi provider practice.  
Dr. A specialty is ortho, BUT he is also board certified with a sub-specialty in hand surgery. 
Dr. B specialty is also ortho, but he does not have a sub-specialty.

A new patient sees Dr. A for hand issues.  The patient also sees Dr. B 2 weeks later for knee issues.

According to CPT guidelines, if I am interpretting this correctly, even though they are both in the same group and both have the same specialty, because Dr. A has a sub-specialty the providers can both bill new patient.

If you look at the decision grid in the CPT manual it appears to support this. Is my thinking correct or am I reading this incorrectly?


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## MnTwins29 (Apr 16, 2014)

I agree with you.  The wording in the CPT guidelines state "...exact same specialty and subspecialty who belong to the same group practice, within the past three years."    The decision tree on the next page in the E/M guidliines, which I am assuming is the grid to which you are referring, supports this as well.   

So, yes, I agree - both Dr. A and Dr. B may bill the services for a new patient.


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## Tonyj (Apr 16, 2014)

MnTwins29 said:


> I agree with you.  The wording in the CPT guidelines state "...exact same specialty and subspecialty who belong to the same group practice, within the past three years."    The decision tree on the next page in the E/M guidliines, which I am assuming is the grid to which you are referring, supports this as well.
> 
> So, yes, I agree - both Dr. A and Dr. B may bill the services for a new patient.



Would that also apply if physcian A shared the same taxometry number as physician B even though they are different subspecialties? I'm referring to a hem/onc scenario.


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## MarcusM (Apr 16, 2014)

Medical Review Related Denials: New Patient Versus Established Patient
http://www.wpsmedicare.com/j5macpartb/resources/new_providers/newvsestpatient.shtml


"New patient" is defined as a patient who has not received any professional services from the physician within the previous three years. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If no face to face encounter has previously occurred between the physician and the patient, then the patient may be coded as a new patient the first time a face to face encounter does occur.

"Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

"An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

"In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available."

"No distinction is made between new and established patients in the emergency department. Evaluation and Management services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department."


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## kathymoon (Apr 17, 2014)

So here's another situation that was just presented to me this morning.  We are a fairly large group of multi-specialty docs.  Dr. A, Internist sees a patient in the hospital.  After discharge, the patient is seen in our wound clinic by Dr. B, Internist.  New or established to Dr. B?

Other scenario, Dr. A is Family Practice and Dr. B is Internist?  New or established?


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