Wiki CMS and New Patients

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dballard2004

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The Medicare Claims Processing Manual, Chapter 12: Physician-Non-Physician Practitioners, Section 30.6.7.A states the following….”Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face to face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

This is a different definition than the CPT manual, so would someone please clarify exactly what CMS is stating here so I can explain this a little more clearly to my providers? Thanks.
 
The key to detemining this is that the doctor has to have a face-to-face visit with the patient. If the physician or another physician of the same specialty in the group has not seen the patient face-to-face in a three year period, then that patient is considered a new patient. If there is no face-to-face contact, then the first time the doctor sees the patient it is a new patient visit.

For example, at our Urgent Care we administer flu shots, PPD's and drug screening. The patient has never been seen by the doctor, but he still issues an order for the nurse to perform these services. If the patient returns at a later date for an illness and the doctor now treats the patient - he will bill a new patient visit for this encounter as this is the first time he is seeing the patient face-to-face.

I hope this helps.
 
Question. Who's name is on the claim for the flu shot? A nurse (RN) can't bill so the claim would fall under the doctor's name. Normally, the payer would say the second visit is established (if it is the same doctor). If the first doctor is Internal Medicine and the second is Orthopaedics then it would be a new patient (specialist). Urgent Care facility may be a little different.
 
ithomas14 said:
Question. Who's name is on the claim for the flu shot? A nurse (RN) can't bill so the claim would fall under the doctor's name. Normally, the payer would say the second visit is established (if it is the same doctor). If the first doctor is Internal Medicine and the second is Orthopaedics then it would be a new patient (specialist). Urgent Care facility may be a little different.
Click to expand...

No, this would not be the second visit. The claim is billed under the doctor. The doctor did not have a face-to-face with the patient and did not bill an E/M therefore there was no face-to-face encounter. This Urgent Care does not bill a facility charge - this is billed as a physician office. A nurse can see a patient as a nurse visit and it is billed under the doctor - the doctor must be present in the office at the time of the procedure, but he does not physically see the patient. He signs the order for the patient to have the shot. Not an issue - it is done all of the time. Medicare pays for all of the flu shots done in other places too. You bill for the drug and the administration - no E/M. This goes for internist office too, although the majority of doctor offices I know only give flu shots to their patients - therefore the patient in that case would have already been established - but the nurse gives the shot and the doctor does not see the patient for an E/M.
 
When explaining this I like to use examples.
The easiest scenario is a patient never seen by anyone in the group practice: New Pt.
Now lets say Drs. A and B are both Cardiologists in the same group practice and Dr. A saw the patient on Jan. 12 of 2009 during a hospital stay, Dr. B sees the patient on March 2nd of 2011 in the office - since the visit with Dr. A is less than three years ago, Dr. B's visit is ESTABLISHED Pt. Drs. A + B are in the same group, same specialty.
Lets add Dr. C to the group practice, who has been with the group for many years. Dr. C however is an Endocrinologist. S/he sees the patient on April 28th 2011. Dr. C is the only Endocrinologist in the group and even though Dr. B saw the patient just 8 weeks ago, Dr. C's visit is NEW Pt. Dr. C is a differenct specialty than Drs. A + B.
In my last example Dr. A saw the patient in the office on Jan. 12 of 2008. When Dr. B sees the patient on March 2nd 2011 over three years have passed and this patient is NEW (again).

Hope this is helpful.
 
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