# 3 Year Rule When Billing E&M Visits



## julieclifton2011

I put this out last week, but by mistake put my question in the wrong post group so I am going to ask my question again, here goes:

I have a doctor who was in a practice last October and has since left that practice and has become employed by our local hospital. Since staring his new practice with the hospital we have taken on a new doctor and a NP. Some of my "old" doctors patients from the practice he left last October have started to transfer to his new practice to see him.  Here comes my questions:

#1-Since we are biiling under a completley new TAX ID do I bill these patients as New for the "old" doctor? (regardless of the 3 years rule)

#2- For the new doctor and the NP who have never seen these patients from the old practice do I bill them as new patients?

Thanks for any imput anyone may like to give me on this matter.


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## DebbiePottsEngland

it is my understanding that the three years follows the doctor where ever he goes.  if the other providers are part of the same group then they are also not new for those patients that have followed the first provider.


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## eadun2000

juliejenkins2005 said:


> I put this out last week, but by mistake put my question in the wrong post group so I am going to ask my question again, here goes:
> 
> I have a doctor who was in a practice last October and has since left that practice and has become employed by our local hospital. Since staring his new practice with the hospital we have taken on a new doctor and a NP. Some of my "old" doctors patients from the practice he left last October have started to transfer to his new practice to see him.  Here comes my questions:
> 
> #1-Since we are biiling under a completley new TAX ID do I bill these patients as New for the "old" doctor? (regardless of the 3 years rule)
> 
> #2- For the new doctor and the NP who have never seen these patients from the old practice do I bill them as new patients?
> 
> Thanks for any imput anyone may like to give me on this matter.



regardless.... they are are billed as established.  It does not matter if they are a new practice.... as long as one provider has already seen the patient wherever in the past three years, the patient is billed as established.  Hope this helps.


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## julieclifton2011

Well if you read in your 2011 AMA CPT manual it reads"A new patient is one who has not recieved any professional services from the physician OR another physician of the same specialty who belongs to the same group practice, within the past 3 years."  

So I would think that my new doctor and new NP not coming from the old practice should be able to see these as new patients.  

Thoughts


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## eadun2000

juliejenkins2005 said:


> Well if you read in your 2011 AMA CPT manual it reads"A new patient is one who has not recieved any professional services from the physician OR another physician of the same specialty who belongs to the same group practice, within the past 3 years."
> 
> So I would think that my new doctor and new NP not coming from the old practice should be able to see these as new patients.
> 
> Thoughts



When you have a new doctor coming into the new practice, EVERY SINGLE PATIENT HE HAS SEEN IN THE LAST THREE YEARS is considered established to everybody in the new practice.


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## julieclifton2011

Sorry I do not agree.  That new doctor is coming into a new practice and billing under a new tax ID number, I feel that it could be billed as a new patient. I don't feel that he shoud loose out on that new patient visit. That is just thought.


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## eadun2000

juliejenkins2005 said:


> Sorry I do not agree.  That new doctor is coming into a new practice and billing under a new tax ID number, I feel that it could be billed as a new patient. I don't feel that he shoud loose out on that new patient visit. That is just thought.



It doesn't really matter if you agree or not.  The guidelines specifically state that it would be an established patient.  If you bill as new then you are fraudulent billing.


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## m.j.kummer

eadun2000 said:


> It doesn't really matter if you agree or not.  The guidelines specifically state that it would be an established patient.  If you bill as new then you are fraudulent billing.



It varies by payer and has everything to do with provider numbers and tax ID numbers nothing to do with facts or patient care.


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## marhiam

I work with a hospitalist that left a family practice, and we have to bill patients in the hospital that saw him as a family doctor as established patients.  To be a new patient it has to be a completely new patient within 3 years no matter where (if we bill as outpatient).


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## julieclifton2011

Let me add this: Same situation, what happens when the "old doctor" retires and leaves the practice and I still have  these patients transferring over from the old practice.  We are still in that "3 year period".  How would you explain not billing a new patient vist for my new doctor and NP in this new practice?


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## jdibble

juliejenkins2005 said:


> Sorry I do not agree.  That new doctor is coming into a new practice and billing under a new tax ID number, I feel that it could be billed as a new patient. I don't feel that he shoud loose out on that new patient visit. That is just thought.



A patient is conisdered established if they were seen within a 3* year period by any physician of the same specialty *in the group.  If your old doctor in his new practice has seen the patient within the three years and his new doctor in his practice sees the patient then it would still be established based on same specialty same practice.



> Let me add this: Same situation, what happens when the "old doctor" retires and leaves the practice and I still have these patients transferring over from the old practice. We are still in that "3 year period". How would you explain not billing a new patient vist for my new doctor and NP in this new practice?



If the old doctor retires and leaves the practice, the patients are still established to the practice and the doctor seeing the patient is still part of that practice - then it would still be established, not new.


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## DebbiePottsEngland

It is my understanding that the NPI number is what the insurance tracks by not the tax id number.  We have had phyisicans move into our clinic from their own and some of our physicians did try to bill as new and were denied because the doctor that joined NPI's revealed him with the practice now.
I could be wrong be we had to change several claims to established patients.


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## FTessaBartels

*Could you be more clear?*

If I understand the scenario correctly, these patients are ESTABLISHED.

To make it easy, let's give these providers names.
Doctor OLD left his old practice and joined your NEW PRACTICE.  Any patients from his old practice who follow Dr OLD to the NEW PRACTICE are established if he provided any face-to-face service within the last 3 years.  

Doctor New and Nurse NP have now joined the NEW PRACTICE .  The rule  states that a patient is considered established if they have received face-to-face services from that provider or any other provider of the same specialty and same practice within the last three years.   So if Dr New or Nurse NP sees one of Dr Old's patients, that patient is considered established ... because the patient has received face-to-face service by another provider of the same specialty and same practice within the last three years. 

If one of Dr Old's patients who was last seen by him 5 years ago, happens to come back to him or to Dr New now ... that patient is a NEW patient (becuase it's been more than 3 years since the last face-to-face service). 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## saagar

It is my understanding that when billing ESTABLISHED patient, the patient is an established patient if he has been seen by a provider of same speciality within the last three year. Tax-id also plays a role in determining this. If we are billing under the same tax-id, then patient is always an established within the three year period. If we are billing under a new tax-id, we can bill the patient as a NEW patient. However, this rule does not apply to Medicare patients - Medicare follows NPI # - if the patient has been seen by a provider within the three year period - the patient is always an ESTABLISHED patient no matter what his tax-id is because the NPI# is the same. Thus you need to check with specific payor you are billing for.


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## FTessaBartels

*Tax ID makes NO difference*



saagar said:


> It is my understanding that when billing ESTABLISHED patient, the patient is an established patient if he has been seen by a provider of same speciality within the last three year. Tax-id also plays a role in determining this. If we are billing under the same tax-id, then patient is always an established within the three year period. If we are billing under a new tax-id, we can bill the patient as a NEW patient. However, this rule does not apply to Medicare patients - Medicare follows NPI # - if the patient has been seen by a provider within the three year period - the patient is always an ESTABLISHED patient no matter what his tax-id is because the NPI# is the same. Thus you need to check with specific payor you are billing for.



The NEW vs established patient rule is PROVIDER specific.  Tax ID makes no difference. Please get the above quote out of your head.  Whether it's Medicare or any other carrier ... CPT is very specific about this. 

*If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED.*  Tax ID makes no difference. 

F Tessa Bartels, CPC, CEMC


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## rthames052006

*With a twist!*

The NEW vs established patient rule is PROVIDER specific. Tax ID makes no difference. Please get the above quote out of your head. Whether it's Medicare or any other carrier ... CPT is very specific about this. 

If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED. Tax ID makes no difference. 

F Tessa Bartels, CPC, CEMC 


Hey Tessa:

Just want to pick your brain about this because mine is spent at the moment.... I've run into a situation and I'm literally on the fence about it.

I work for a Medical Group so we have several FP, IM practices using the same tax id#.  We have a patient who transferred their records from one FP under our umbrella to another FM under our umbrella.  The new office wants to bill a new patient visit for this patient today.  

Do the same rules apply here that you mention in your above response now.  My personal thought is "no, the new FP under the same umbrella can't bill a New patient visit"  but I'm on the fence. 

Or can they bill a new patient visit because it's a physician who hasn't seen this patient and it's not the same practice BUT it's under the same "umbrella" ( tax id#)

I'm going to check my mac to see if they have any info on this as well.

Thanks


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## rthames052006

*I got it...*

Just found my answer in the CPT book....

" A new patient is one who has not received any professional services from teh physician or antoher physician of the exact same speciality and subspecialty who belongs to the sme group practice, withint eh past three years".

So this patient that I have would be considered a new patient to this different group practice.

It's nice when you can answer your own question ( after you've asked it) LOL


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## LindaEV

Roxanne, per Medicare, same tax id & same specialty = same person. We have several clinics under the same tax id "umbrella". We do NOT charge a new patient when the patient switches clinics. I asked this very question to our MAC. 

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0727_newpatientservices.shtml


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## LindaEV

FTessaBartels said:


> The NEW vs established patient rule is PROVIDER specific.  Tax ID makes no difference. Please get the above quote out of your head.  Whether it's Medicare or any other carrier ... CPT is very specific about this.
> 
> *If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED.*  Tax ID makes no difference.
> 
> F Tessa Bartels, CPC, CEMC



*Comepletely agree. Bypassing the claims system due to different tax ID's, abd getting your claim paid , does not make it right. *


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## Kim M Gordon

I believe that the "3 year rule" follows the patient and not the provider, if that was the case and the provider switched practices often and the patient followed them, they would be charged new pt visits more than allowed, i believe that it reads that the "patient" has not been seen in 3yrs by a provider in that specialty or of the same specialty...


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## rthames052006

LindaEV said:


> Roxanne, per Medicare, same tax id & same specialty = same person. We have several clinics under the same tax id "umbrella". We do NOT charge a new patient when the patient switches clinics. I asked this very question to our MAC.
> 
> http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0727_newpatientservices.shtml



Thank you LindaEV for that link! It is greatly appreciated!


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## cisaia

*New provider  to practice  - 3 year rule*

I have a new provider that just joined our practice . 

We are now seeing some of her patients from her previous practice . Which we are no way affiliated with. 

I billed these visits as new patients and I am getting denials that these are established patients. Is this correct ?


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## Pathos

Hello,

If the provider has seen the patient before within the 3 year threshold, it doesn't matter which practice the provider works/worked for. In your example, the patient was seen before in a previous practice, and is seen again at the provider's new practice. The denial is correct in since the provider did see the patient, face-to-face within the 3 year threshold.

Here is a good reference from my local MAC, which also has some good examples:

Noridian - New vs. Established


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