Medicare Compliance & Reimbursement

Question: We saw a patient over a year ago for a thyroidectomy, and now the patient returned to our practice with sinus complaints. The physician performs a nasal endoscopy. Should we bill the nasal endoscopy encounter as a new patient since she's coming back for a different reason and seeing a different otolaryngologist?

Answer: No, you should not bill this case as a new patient. You should bill this as an established patient for several reasons.

Caveat: This rule applies as long as all the physicians in your group bill under the same group number.

Change in 2012: The AMA added distinction to the three year rule in the CPT® 2012 E/M narrative. The CPT® manual now says (emphasis added): "Solely for the purposes of distinguishing between new and established patients, professional services are those face to face services rendered by a physician and reported by a specific CPT® code(s). A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years." This means if the general otolaryngologist treats a patient within a group, and then within three years of that treatment, she comes back to see the otologist in the same group, the visit can be considered a new patient visit, per 2012 CPT®. For the patient to be coded as a new patient, the otologist has to have a taxonomy code indicating that he is an otologist, and the general otolaryngologist a taxonomy code for general otolaryngology.

However, in an open door forum call in January 2012, CMS clarified they are not following the new AMA CPT® guidelines for new versus established patients. They still consider a patient seeing a subspecialist in the practice an established patient if they had seen another subspecialty within the past three years. This is another instance where the CMS definition differs with the AMA CPT® definition.

Distinction: The rules change a bit if you are operating in a multi-specialty practice. If a physician of a different specialty sees a patient for the first time, you may consider the patient to be "new" even if he has seen other physicians in other specialties within the group practice during the previous three years.