Wiki Billing New & Est. Pt at the same time

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tiffmand

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I am a medical auditor and came across a claim that was billed with an new patient visit - I am very interested in learning about providers billing a patient as new and established at the same time.

I work in the medical field. I came across a claim where the provider billed three lines of service. A 99386 New Patient - For the preventative visit - dx - Well GYN exam. On the next line they billed the Q code which is ok, and let me add, they also attached a 25 modifier to the 99386. On the 3rd line they billed a 99213 - Established Patient - Office or other outpatient viist, attached a modifier 25 to this code as well.

Can a provider's office bill this way - any provider seeing a patient for any type of visit?

Can they bill a new and a established patient E/M on the same claim?

The insurance company paid all 3 lines. They covered the preventative at the full allowance and then paid for the office vist @ 50%. Is this right? It does not seems to make since that the provider would bill both at the same time. The CPT and CMS guildeliness appear to agree that in "history" a patient is consider established once there as been a face to face.

Last thing, both E/M codes were attached to the same diagnosis code. The Well GYN Exam.

Thank you so much.. any help would be appreciated.

TiffanyM.
 
From what I was informed in both my CPC and CPMA courses and training on the job, is that a provider can bill a 99386 (new patient CPE) and a 99213 (established patient level 3) on the same date of service. Reason: like you described below-"The CPT and CMS guildeliness appear to agree that in "history" a patient is consider established once there as been a face to face." If a patient is new and seen for their CPE, now that they have established their history with the provider, the insurance can be billed for their "acute sinusitis" as an established patient level 3.

Also, in my state, most carriers will not accept a new patient CPE code and a new patient office visit code on the same day.

In the case you described below I would have billed as follows: 99386, 99213 (mod -25), G0101, and Q0091.

Hope this helps.
 
They can do that if they establish and document that the information for the second E/M service is completely seperate from the first E/M service. I can't imagine getting anything higher than 99213 though.
 
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