Clear Up Your New Patient Confusion With 4 Guidelines

Use CMS specialty codes to determine patient status and ensure just payment
If you report a level-three established patient visit when you could have coded it as a new patient visit, you just cost your practice almost $50.

In the multispecialty world, internists, endocrinologists, registered dieticians and cardiologists often work side-by-side in the same clinic - referring patients back and forth all the time. You might think you can easily differentiate between new and established patients, but the choice is not always black and white.

If a physician sees a patient who is already established under another physician in your practice, the medical specialties involved will determine whether you bill that patient visit as new or established. But before making that determination, you must understand the rules governing when to bill a new or established patient.

1. Bill a New Patient for First Face-to-Face Service. You should bill a new patient when the physician has "never before performed a face-to-face service on the patient" that you could report with a CPT code, says Shannon O. Smith, CRTT, CPC, consultant auditor with Doctors Management in Knoxville, Tenn. Phone calls, record reviews and other non-face-to-face services do not count as a new patient service.

Time's up: You should also bill a new patient whenever the physician has not treated the patient "within a three-year time frame," Smith says. So if the physician treated the patient three and a half years ago, that qualifies as a new patient.

Place doesn't matter: The location of patient encounters can vary, but the patient is not new if the physician rendered a face-to-face service in the past, says Terri Fischer, CPC, CMC, manager with LarsonAllen Health Care Group in St. Louis, Mo. For example, a new patient visit occurs in the hospital, and the same physician then treats the patient in the office. You would report that office visit as an established patient visit.

2. Bill Established for a New Physician's Transferred Patients. If a new physician joins your practice, you should bill established patient visits for any patients who follow him to your practice. Although a patient may be new to your practice, she is not necessarily new to the treating physician.

Don't be fooled: Disagreements about this policy sometimes arise if the new physician can't obtain the patient's medical record from his last practice, Fischer says. If the physician has to reconstruct the record, some billers argue that the visit is a new patient. Not so, most carriers and coders agree.

3. Know the Multiphysician Catch. Suppose a patient sees one physician, and then on a later date sees a different physician within the same practice. You can only bill a new patient visit for the [...]

- Published on 2004-10-19