# New/Established patient with Medicare



## almadcpc (Sep 1, 2010)

Help!

I work for the department of Medicine Medicare has denied our new patient claim stating that pt is established even is the patient has seen with in a different specialty.  Example: Patient was seen in the dept of GI and then came in to Cardiologist.
Per Medicare guidelines the patient can be seen as a new patient if they are seen in different specialties and have a different NPI and tax ID. Can anyone HELP.


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## RebeccaWoodward* (Sep 2, 2010)

almadcpc said:


> Help!
> 
> I work for the department of Medicine Medicare has denied our new patient claim stating that pt is established even is the patient has seen with in a different specialty.  Example: Patient was seen in the dept of GI and then came in to Cardiologist.
> Per Medicare guidelines the patient can be seen as a new patient if they are seen in different specialties and have a different NPI and tax ID. Can anyone HELP.



You are correct and I would certainly appeal your claim if the visit to the Cardiologist was the intial visit.

Refer them to section *30.6.7*...

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

http://www.cms.gov/manuals/downloads/clm104c12.pdf


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## almadcpc (Sep 2, 2010)

Appeals have been submitted to Medicare but our appeals are still being review by the new auditing dept they have and they keep denying our claims as established….

Thanks for your help


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## ithomas14 (Sep 5, 2010)

We are having the same problem. We think the doc's specialty is somehow not associated with NPI. Let us know what happens.


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## kbarbag (Sep 6, 2010)

We has the same problem and found out our Dr's were credentialed as Internal Medicine and not their specialty.


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## efuhrmann (Sep 7, 2010)

Our doctors are listed as Internal Medicine-Cardiology or Internal Medicine-Gastroenterology.  Don't know how that happened-if it's from a list that gets "clicked" when credentialling or if it is something within our system but we have the same problem..  It's almost like it gets read as Internal Med and doesn't see the "Cardiology" or "gastroenterology" after the hyphen.


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## Peter Davidyock (Sep 11, 2010)

kbarbag said:


> We has the same problem and found out our Dr's were credentialed as Internal Medicine and not their specialty.



Sounds like they are all the same group then.
No way around that. Unless your credentialing dept is willing to try to work it out.


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