Do you know all the 3-year rule details? You may think that deciding whether you have a new or established patient is the easiest part of choosing an E/M code. But even this decision has a few hidden pitfalls. Avoid them with this guide to the ins and outs of new and established patients. Look at Group to Determine Patient Status Generally, you should consider a patient to be -established- if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.
A CMS transmittal (R731CP, change request 4032) reinforces the agency's -new/established- patient policy. You can see it on the Web at
www.cms.hhs.gov/transmittals/downloads/R731CP.pdf. The related MLN Matters article is at
www.cms.hhs.gov/MLNMattersArticles/downloads/MM4032.pdf.
CMS- Definition of New Patient A -new patient- is one who hasn't received an E/M or other face-to-face service -from the physician or physician group practice (same physician specialty) within the previous three years.- Diagnostic test interpretation without a face-to-face service does not change a new patient into an established one.
Established patient example: A patient comes to your office after being diagnosed with breast cancer. Although this is oncologist A's first time meeting the patient, oncologist B, in the same group practice, saw the patient two years ago (for the same or a different diagnosis). In this case, the patient is established.
Tip: Don't let different locations lead you astray. If your practice has multiple locations, and a physician in location -A- sees the patient in January but a physician in location -B- sees the patient the following December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.
And remember, the patient's diagnosis doesn't matter when choosing patient status. If Oncologist A saw the patient for a primary malignancy, and Oncologist B, in the same group, later sees the patient for secondary malignancy treatment, use an established patient code for the visit to Oncologist B.
New patient example: A primary-care physician recommends that a 60-year-old female see an oncologist in your group. One of the physicians in your practice interpreted some test results for the same patient the previous year but provided no face-to-face service.
In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.
According to section 30.6.7 of the Medicare Claims Processing Manual, [...]
