# New or Established?



## dhuston (Jun 10, 2009)

A patient was sent to our out patient IR clinic by his oncologist to be seen by Dr. A for RF ablation of liver cancer on 5/19/09.  Prior to this, Dr B inserted a tunneled catheter in the hospital on 3/6/09 and Dr C did a port check in the hospital.  No E&M services were provided in the hospital.  Drs A, B, and C are all in our group.

So this visit in the IR clinic would be a new patient because he's there for a new condition and we've never done an E&M....is that right?

Thanks,
Diane Huston, CPC,RCC


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## mitchellde (Jun 10, 2009)

I say estb but I am interested in what others take is.


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## RebeccaWoodward* (Jun 11, 2009)

I agree with you Michelle...Established.

*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.

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

30.6.7


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## LLovett (Jun 11, 2009)

I agree, established, unless this doctor is a different specialty than the others.

Laura, CPC


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## dhuston (Jun 11, 2009)

I checked and Dr. A's subspeciality is cancer treatments.  Drs B and C are neuroradiologists.  Dr. A would never perform a neuro surgery and Drs. B and C would never perform the RF ablations or chemotherapy on cancer patients.  Based on this then, it would appear to be a new patient?

Diane

P.S. Thanks for that link to the Medicare manual


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## LLovett (Jun 11, 2009)

Yes, it would be a new patient.

Laura, CPC


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## mitchellde (Jun 11, 2009)

Not if all docs are in the same tax ID.  then once they are seen by one doc they are established to the practice.


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## LLovett (Jun 11, 2009)

You can have multiple specialties under one tax id#. If they are different specialties the same patient can be new multiple times under the same tax id#. 

Rebecca posted the guideline about same physician or specialty above.

Laura, CPC


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## mitchellde (Jun 11, 2009)

Yes it says same group practice.


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## LLovett (Jun 11, 2009)

"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."

They specify it has to be from the same specialty in the group practice to be considered established.

For instance, one of my family practice providers refers a patient to one of my cardiovascularthoracic surgeons, that is a new patient to the CVT even though they are billing under the same tax id.

We even have an email from WPSMedicare stating they consider the CVT PAs to be different specialties from the CVT surgeons they work for.

Laura, CPC


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## Karolina (Jun 11, 2009)

In order to be sure if this is a same or different specialty you need to see how these providers are credentialed with the carrier. If they are all credentialed to the same specialty, regardless of their subspecialty, then it is established. If they are credential to different specialties then it is new (all other conditions for new must be met, of course). For example, if Drs. B and C are credentialed as Neuro-surgeons, and Dr. A is credentialed as oncologist then it is a new pt for Dr. A (same group, different specialty).


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## mitchellde (Jun 11, 2009)

I think this is a matter of interpretation also.  Here is how I have run in to this which then forms my interpretation.. I work with one physician group, they are organized as a group practice under the same tax ID... different specialties, however when the ortho doc billed as a new pt for a pt estb with family practice, the claim was denied as the patient was establishe to the group practice.  A different group I work with all orthos in the same building all have their own individual tax ID but they all practice in the same building under the same business name, when Dr. B sees a pt having already been seen by Dr A, the claim for new patient was denied as the patient was already estb with the "practice".  So when I see same group practice (same physician specialty) I take it that they are covering both types of scenarios.  Your interpretation is that the parenthetical reference is a clarification for group practice.   And now we are all confused!


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## dhuston (Jun 11, 2009)

I appreciate all the responses.  Just to add a little more confusion...it's been suggested to me that perhaps the specialty in my case would be Interventional Radiologist vs. Diagnostic Radiologist rather than cancer-treating doctor vs. neuro-treating doctor since both are Interventional Radiologists?

While my IR doctors have different areas of expertise, I guess the most explicit we get when credentialing them is whether they are interventional or diagnostic.  Although all interventional docs are called upon to help read xrays too.  And that leads me to wonder if radiology groups have specialties at all.


Diane


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## LLovett (Jun 12, 2009)

I would suggest you check with your carrier on how they are credentialed.

I have worked for large multispecialty groups, one had over 200 providers in 27 different specialties and the current has approx 500 providers and I am not sure how many specialties (thankfully I am only responsible for 7 different specialties at this time). As I stated earlier WPSMedicare advised us that if our CVT PA does a consult inpatient and has the patient follow-up outpatient with the CVT surgeon they work for, it is a new patient because they consider them different specialties. 

All my providers have the same tax id# and I have never had a problem with any insurance, be it governmental or commercial, rejecting new patient visits for different specialties.

This is from CMS

"Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group."

Laura, CPC


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