Wiki E/M coding for Specialty Observation services

[chamby4054@gmail.com]

My provider rendered urological services to an established patient w/in our practice, while in observation status at a local hospital, after a referral was initiated by the admitting provider.

So I submitted code 99204 and I'm receiving a denial saying that this is not a new patient. While the patient is an established patient with our practice, it was a new referral request for services rendered at a different service location.

So are you not allowed to bill a new patient E/M code as a specialist if a referral is received for evaluation under observation? I've checked the CMS website and most of the guidelines seem to apply to the admitting/attending physician rendering obs services.

The patient has UHC Medicare.

Any input would be greatly appreciated, thank you!

Liz C.

 

[cgaston]

A new patient is one who has not received ANY services within the past 3 years.

It does not matter that your doctor saw them in a different location...if he/she provided any services within the past 3 years the patient is an established patient.

 

[thomas7331]

Agreed, you cannot bill a new patient visit if the patient is established to that physician, even if consulting for a new problem outside of the office.

The CMS guidelines for consulting physicians can be found in this helpful publication: https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM6740.pdf

Your situation is address on page 5 where it states 'Examples of where a new patient office is not billable: ... The consultant furnishes a consultation to a known beneficiary in an outpatient setting different than the office (e.g., emergency department) observation where the patient was seen in the past three years. As the patient has been seen by the consultant within the past three years, a new patient office visit cannot be billed.'