# New Patient versus Established Patient



## ahouse (Apr 27, 2009)

I work for a carrier and I'm having a philosophical disagreement with a provider.  

They have a large, multispecialty clinic under one TIN.  My Carrier (and I think everyone generally agrees) has determined that a 'group practice' is defined by Tax ID.  

This practice wants to be able to bill two new patient visits for one patient who has seen two different doctors of the same specialty from two different locations for two different diagnosis codes.  To better explain:

01/01/01 99204   171.2   Dr A. is a General Surgeon
01/25/01 99204   682.6   Dr B. is a General Surgeon

Both dates of service are billed as POS 11, both are billed under the same TIN with the same billing address.  

The practice wants written proof that these can not both be billed as new patient.  

Is the term group practice defined by CMS or the AMA somewhere?  Any help you can give would be greatly appreciated!


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## RebeccaWoodward* (Apr 27, 2009)

This is about as clear as it gets.....

http://questions.cms.hhs.gov/cgi-bi...std_adp.php?p_faqid=6663&p_created=1139848911

http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM4032.pdf

As for all other E/M services except where specifically noted, carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).


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## Lisa Bledsoe (Apr 27, 2009)

*I really meant yes*

Sorry, I don't know how to change my answer...


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## RebeccaWoodward* (Apr 27, 2009)

One discrepancy does still exist. CMS restricts the use of the definition of “same physician specialty” to the specific specialties defined by CMS with two-digit physician specialty codes. This list of these specialties and their two-digit designations can be found on the Internet at:

http://www.cms.hhs.gov/GEM/Downloads/GEMMethodologies.pdf

AMA (CPT), however, does not specifically define what constitutes a physician of “same physician specialty.”

This discrepancy can make a practical difference when a patient is seen in a practice by a physician who is practicing a specialty that is not defined by a two-digit CMS code.

http://www.jucm.org/2009-feb/coding.shtml


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## Lisa Bledsoe (Apr 27, 2009)

Lisa Curtis said:


> Sorry, I don't know how to change my answer...



I do believe that group practice is one thing, same specialty is another and needs to be addressed.


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## ahouse (Apr 27, 2009)

I actually found the answer I was looking for, but decided to post it here for anyone who might search this out later.  I found this on the Social Security Act website.  It gives a clear definition of Group practice:

The definition of a group practice as set forth in section 1877(h)(4)(A)of the Social Security Act:

“The term ‘group practice’ means a group of 2 or more physicians legally organized as a partnership or similar association:
	(i) in which each physician who is a member of the group provides                  substantially the full range of services which the physician routinely provides through the joint 	use of shared office space, facilities, equipment and personnel, 
	(ii) for which substantially all of the services of the physicians who are members of the group are provided through the group and are billed under a billing number assigned to the group and amounts so received are treated as receipts of the group, 
	(iii) in which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined, 
	(iv) except as provided in subparagraph (B)(i) [which relates to profits and productivity bonuses], in which no physician who is a member of the group
	directly or indirectly receives compensation based on the volume or value of referrals by the physician, and 
	(v) in which members of the group personally conduct no less than 75 percent of the physician-patient encounters of the group practice”


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## 1071471 (Apr 27, 2009)

*New Patient vs. Established Patient (different specialties)*

Hi All,

I am dealing with this same issue altough I am from a multi-specialty medical group that has over 15 different specialties within the group who all specialize in treating cancer. (i.e. medical oncologist, radiation oncologist, Neurosurgery,HEENT, etc.) My concern is that our local carrier is currently denying all New Patient codes: 99201-99205 after the first New Patient service is paid. For example, Surgeon X bills a new patient code and then refers the patient to either Medical Oncology or Radiation Oncology because the tumor is unresectable. Dr. Oncology bills another new patient code (New to the specialty) and our carrier is denying Dr. Oncology's code stating, the patient is already established. This is very frustrating considering we have a large volume of new patient codes amongst the different specialties. 

Any thoughts??

Medicare Claims Processing Manual, Chapter 12, Section 30.6.7
2009 CPT Book, E/M Guidelines, Page 1
MLN Matters Number: MM4215


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## Karolina (Apr 27, 2009)

*Reply to nmadame's question - onco*

I am very familiar with that issue. So far as I know the Medical Oncologists, surgical oncologists, and Radiation Oncologists are in different specialties and should be able to use the New Patient codes (with proper documentation and if all other criteria are met, of course).


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## RebeccaWoodward* (Apr 27, 2009)

Makes me wonder if it is a registration/credentialing issue with the carrier. You have to be so careful when submitting contracts to carriers.  One little error could become so messy.


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## Karolina (Apr 27, 2009)

So true! If a provider changes specialties and the regstration/credentialing is not updated, that can be cause of conflict as well.


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