Medicare Compliance & Reimbursement

If three years have passed since his last visit, he's a new patient again.

Heads up, physicians: The Centers for Medicare and Medicaid Services tweaked some of the rules for evaluation and management coding in a new transmittal (731), dated Oct. 28.
 
For example, CMS clarified the definition of "new patient" for E/M coding. Experts say the policy hasn't really changed, but CMS is explaining it differently, and it can provide a useful refresher course. According to CMS someone is a new patient if none of a practice's physicians have seen him face-to-face in the past three years.

In other words, if a physician interpreted a patient's test results or did some other non-face-to-face service in the past three years, he can still consider that person a new patient the next time he comes into the office, according to consultant Devona Slater with Auditing for Compliance & Education in Leawood, KS.

Also, CMS says it won't pay for any E/M services on the same day by physicians in the same practice and same specialty--unless the claim provides documentation proving that the visits were for unrelated problems. 

Further, CMS says physicians can't bill for a level one E/M service (such as 99211) on the same date as a drug administration service such as chemotherapy or infusion--even if they use the 25 modifier. Billers sometimes mistakenly bill for 99211 on the same date as a drug administration code, notes Slater.