# new vs established patient in new physician group practice



## KPEAK (Feb 14, 2012)

need comments concerning a patient who was previously seen by an endocrinologist in a previous group practice---physician has left that practice and joined a new group---is the  patient a "new" patient to the new group practice (new ein#, new NPI for practice, etc) or established since patient had been seen by physician in the previous practice...Thank you!


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## jmcpolin (Feb 14, 2012)

hmm same NPI but different tax ID, I would assume a new pt would get denied based on the NPI but I am curious to see what other people think.


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## wess0808 (Feb 14, 2012)

We just went through this. Although the patient is new to the group, the patient is not new to the physician.  It would be an established patient.


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## 1lisajoey (Feb 14, 2012)

*New vs Established*

I was just have ing this discussion today regarding my Med Oncs vs Rad Oncs. I am attaching the current definition from MLN.

"A new patient is defined as an individual who has not received any professional
services from the physician/non-physician practitioner (NPP) or another physician of the
same specialty who belongs to the same group practice within the previous three years.
(Same group is determined by Tax ID and NPI Organization number billed on claims)

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."


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## DeeLonna (Feb 15, 2012)

1lisajoey said:


> I was just have ing this discussion today regarding my Med Oncs vs Rad Oncs. I am attaching the current definition from MLN.
> 
> "A new patient is defined as an individual who has not received any professional
> services from the physician/non-physician practitioner (NPP) or another physician of the
> ...



I agree, however, it is my understanding there is a new guideline that allows Speciality MDs to code as a new patient when being seen as a Specialist for treatment of new diagnosis.  Are you familiar with this?


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## MandyFlagg (Mar 16, 2012)

I am also wondering the same thing, I was just in a seminar that says it is based on tax id and they are working to be able to drill down to taxonomy, however I am now in a different seminar and they are instructing that it is based on SUB specialty. We are currently getting denials from this but I cannot find the direction.....

Does anyone have documentation?

Thanks


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## FTessaBartels (Mar 19, 2012)

*Established*

I'll try to make this simple.

Dr A sees Patient X at Practice Green in February 2011  
Dr A leaves Practice Green for Practice Red in October 2011
Dr A sees Patient X at Practice Red in February 2012

Patient X is STILL an established patient because the physician has provided a face-to-face service to the patient in the last three years. 

If Dr A is not available and Dr B (who has the same specialty or subspecialty in Practice Red sees Patient X ... the patient will still be considered established, because Face to face services have been rendered by the physician (or another physician in the same practice, same sub/specialty) in the last 3 years. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## FTessaBartels (Mar 19, 2012)

*Ask yourself these questions*

Q1 - Has this patient been seen by ANYONE in this practice in the last three years?

NO?  - it's a new patient

YES?   next question

Q1 - Has this patient been seen by THIS physician or any other physician in THIS practice with the same specialty / subspecialty (as appropriate).

NO?  It's a new patient
YES?  Established.

Location makes no difference, tax ID makes no difference.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## MandyFlagg (Mar 19, 2012)

That is opposite of what I am seeing in denials as well as what I was told in the seminar last wednesday.  My circumstance is I have one practice - 4 cardiologist - 2 CVT - 2 EP doc's.  This is all ONE practice under ONE tax-ID.  We are seeing denials not only for new vs established patients but with patients in a global period.  The very knowledgable gentleman that spoke at last wednesday's seminar said that this was still based on group (tax ID) and later this year the guidelines would change to go all the way down to taxonomy because Medicare was looking at bringing consultations back.

Any thoughts?


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