# New office visit after in patient consult?



## least

Patient seen by oncologist as a consult on an in-patient basis.  When patient is discharged from the hospital and has a follow-up visit with the oncologist a week later is the patient considered a new patient or established?


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## dclark7

Pt is an establlished patient if they have received ANY professional services from the physician within the past three years, there is no allowance for different place of service.  So if the pt was seen in the hospital then comes to the office that pt is considered established.


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## PKellogg

Can anyone tell me where I can find an actual guideline to support this answer?  We are working on Audits and this question keeps coming up.

 Patty Kellogg, CPC


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## RebeccaWoodward*

Other than you CPT book, refer to CMS's definition.

*A. Definition of New Patient for Selection of E/M Visit Code*

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. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

30.6.7

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


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## Shoesan27

*Nerve Conduction study*

If a provider sees a patient in the hospital for a Nerve conduction test and EMG, then sees the patient in his office several weeks later, does he bill a New patient or established patient visit?


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## jkyles@decisionhealth.com

Shoesan27 said:


> If a provider sees a patient in the hospital for a Nerve conduction test and EMG, then sees the patient in his office several weeks later, does he bill a New patient or established patient visit?



The patient is established. New/Established status is based on time, not place of service. The patient will also be established for any provider of the same specialty. See the decision tree in the beginning of your CPT manual for more details.


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## Shoesan27

*Nerve Conduction study*

Thank you.  This is what I thought. The provider wants to bill a new patient visit because a E/M was not billed in the hospital. I have been trying to explain that he cannot do that, but cannot find any specific guidelines, just that if ANY Professional services or Face - Face  services were preformed, by the same provider or provider in his group with the same specialty within 3 years you cannot bill as a new patient.


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## jkyles@decisionhealth.com

Shoesan27 said:


> Thank you.  This is what I thought. The provider wants to bill a new patient visit because a E/M was not billed in the hospital. I have been trying to explain that he cannot do that, but cannot find any specific guidelines, just that if ANY Professional services or Face - Face  services were preformed, by the same provider or provider in his group with the same specialty within 3 years you cannot bill as a new patient.



Yes, it's tricky but really worth getting right. A couple of years ago a local health system had to pay a settlement because a practice it purchased had been coding established patients as new.


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## Pathos

Shoesan27 said:


> Thank you.  This is what I thought. The provider wants to bill a new patient visit because a E/M was not billed in the hospital. I have been trying to explain that he cannot do that, but cannot find any specific guidelines, just that if ANY Professional services or Face - Face  services were preformed, by the same provider or provider in his group with the same specialty within 3 years you cannot bill as a new patient.



You're correct. Per CMS E/M guidelines on page 4 (usually always helpful when you can direct people to official references):

_PATIENT TYPE
For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.
*New Patient*: An individual who did not receive 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 3 years.
*Established Patient*: An individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years._


My local MAC (Noridian):

_*New Patient*
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation.

*Established Patient*
Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.

Clear and concise medical record documentation is critical to providing the patients with quality care. When billing for a patient's visit, select the level of E/M that best represents the service(s) provided during the visit. Services must meet specific medical necessity requirements and the level of E/M performed, based on the CMS 1995 This link will take you to an external website. or 1997 This link will take you to an external website. Documentation Guidelines for E/M Services.

The rationale for new versus established patient is based on the provider's National Provider Identifier (NPI)._


If Noridian is not your local MAC, it might be worthwhile locating them and they will most likely have an educational page to show your practice manager/providers.

Hope these references are helpful!


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## lmccormack652

Pathos said:


> You're correct. Per CMS E/M guidelines on page 4 (usually always helpful when you can direct people to official references):
> 
> _PATIENT TYPE
> For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.
> *New Patient*: An individual who did not receive 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 3 years.
> *Established Patient*: An individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years._
> 
> 
> My local MAC (Noridian):
> 
> _*New Patient*
> Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.
> 
> For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
> 
> If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation.
> 
> *Established Patient*
> Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.
> 
> Clear and concise medical record documentation is critical to providing the patients with quality care. When billing for a patient's visit, select the level of E/M that best represents the service(s) provided during the visit. Services must meet specific medical necessity requirements and the level of E/M performed, based on the CMS 1995 This link will take you to an external website. or 1997 This link will take you to an external website. Documentation Guidelines for E/M Services.
> 
> The rationale for new versus established patient is based on the provider's National Provider Identifier (NPI)._
> 
> 
> If Noridian is not your local MAC, it might be worthwhile locating them and they will most likely have an educational page to show your practice manager/providers.
> 
> Hope these references are helpful!



I know this is a late chime in, but this very situation just came up in my neurology group.  Both an EMG and a Nerve condution study are considered diagnositic testing.  CMS states:  "An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient."


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## shanamarie

lmccormack652 said:


> I know this is a late chime in, but this very situation just came up in my neurology group.  Both an EMG and a Nerve condution study are considered diagnositic testing.  CMS states:  "An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient."


So would you not consider an EMG to be a face to face service?  The provider would be performing and interpreting the results.  In the example of the xray or ekg the provider doesn’t typically see the patient they just interpret the test.


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## CodingKing

lmccormack652 said:


> I know this is a late chime in, but this very situation just came up in my neurology group.  Both an EMG and a Nerve condution study are considered diagnositic testing.  CMS states:  "An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient."





shanamarie said:


> So would you not consider an EMG to be a face to face service?  The provider would be performing and interpreting the results.  In the example of the xray or ekg the provider doesn’t typically see the patient they just interpret the test.



For the interpretation of diagnostic they they are referring to services that are performed remote from the patient. So example code for interpretation and report only code, or modifier 26 on an x-ray for example. If the physician was present in the room with the patient when the EMG is done then its now established.


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## sycurlytop

I have a good one for you all. So our residents are on call, the ED calls in for an consult. The resident does a procedure and I write it off as non-billable as i have no Faculty attestation due to none present. Then they come to the office for a follow up, is this new or established as i will have Faculty present and an attestation.


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