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Wiki Hospital coding & office
- Thread starter Jashani1
- Start date
btadlock1
Guest
If the doctor provided professional services to the patient (eg, did something that has a CPT code), within the past 3 years, then technically, the patient's established, even if they've never set foot in your clinic. It gets a little tricky when you consider that some providers are employed by a hospital and have their own separate private practice, and use 2 different tax ID's - in that situation, you may be able to bill a new patient charge, but otherwise, I'd go with an established code.
FTessaBartels
Guest
Established
The different tax ID is immaterial. The physician has one NPI number and that will govern making this patient an established patient when s/he eventually comes to the office.
Hope that helps.
F Tessa Bartels, CPC, CEMC
The different tax ID is immaterial. The physician has one NPI number and that will govern making this patient an established patient when s/he eventually comes to the office.
Hope that helps.
F Tessa Bartels, CPC, CEMC
Pam Warren
True Blue
That's correct, Tessa. The provider's/facilities' TIN has nothing to do with new/established patient status. This is a common misconception.
If the patient was seen at the hospital by your provider, and again at the office, at an outpatient clinic, or at a Wal-Mart clinic, it's still an established patient TO YOUR PROVIDER. Even if he moves to another practice location and brings that patient with him...it's an established visit.
That's why New Patient issues are on the OIG radar all the time!
If the patient was seen at the hospital by your provider, and again at the office, at an outpatient clinic, or at a Wal-Mart clinic, it's still an established patient TO YOUR PROVIDER. Even if he moves to another practice location and brings that patient with him...it's an established visit.
That's why New Patient issues are on the OIG radar all the time!
btadlock1
Guest
Just wanted to add...
Group physicians have 2 NPI's - an individual (rendering) and a group (billing). The NPI that governs new versus established encounters is the billing NPI (the one that goes in box 33a on the CMS-1500). I usually just say Tax ID, because that is also standard across the group.
Group physicians have 2 NPI's - an individual (rendering) and a group (billing). The NPI that governs new versus established encounters is the billing NPI (the one that goes in box 33a on the CMS-1500). I usually just say Tax ID, because that is also standard across the group.
I would not agree with you.
If the patient has received a face-to-face professional medical service from the physician within the past three years and that encounter was reported by means of one or more CPT codes, then the patient would be considered an established patient.
Now, whats the difference where the Dr worked and what billing(group) NPI or tax ID the services was billed with? the service still was provided by the same Dr. Otherwise, the Dr would change the practice and see all his/her established patients as "new" since the billing NPI would be different.
btadlock1
Guest
It matters when you're talking about the patient seeing multiple physicians in a group practice. If the patient is seen by a provider, then seen by a second provider of the same specialty in the same group practice (as identified by either their billing NPI or Tax ID, which should be the same for all providers in the same group practice), the patient is considered established for the second provider, regardless of whether or not they've ever seen the patient before. However, both doctors could be in the saem group, and if they're different specialties, both could see the patient as "new", even at the same location.
Group physicians don't necessarily have to be located in the same facility, so it is possible for a patient to see one physician in a group practice in the hospital, and see a different provider of the same specialty, who belongs to the same group, at a different location (eg, a clinic). The New/Established patient criteria for group physcians, isn't based off of location, it's based off of who is in the group, and what specialty they are. If the question is regarding the same physician seeing the patient at 2 different locations, then the visit is established the second time, regardless of group affiliation/NPI/Tax ID. I was incorrect in saying that it might make a difference if the physician is associated with more than one practice - I apologize if that caused any confusion.
These articles cover most scenarios for this question:
http://www.supercoder.com/articles/...ew-or-established-gets-optimum-reimbursement/
http://www.aafp.org/fpm/2003/0900/p33.html
Pam Warren
True Blue
The original question had to do with a single provider...not a group practice, and as such, the TIN (or NPI for that matter) play no part in the new/established patient question. Not all providers use the same NPI for the same TIN, for example, we have providers who work for our physician corporation (one TIN) and also work for their private practice (different TIN). The new/established patient rules for them do not change based on the different practice settings that they work in. So to use TIN as a qualifier for a single physician is misleading.
I do agree that the practice/specialty considerations play a part when patients see other providers in the same group. But again, the original post had to do with a single physician, and the comment about separate TINs for the same doctor leading to possibly billing a new patient visit is incorrect. I just wanted to clarify, because this board can confuse new coders who just want the right answer!
I do agree that the practice/specialty considerations play a part when patients see other providers in the same group. But again, the original post had to do with a single physician, and the comment about separate TINs for the same doctor leading to possibly billing a new patient visit is incorrect. I just wanted to clarify, because this board can confuse new coders who just want the right answer!
this was the original question. the answer is "NO". the patient is established. I dont know why btadlock1 brings up all this different TIN or NPI or different location issues here. I think it is a simple question requiring simple answer. No need to bring up different specialty/group or TIN/NPI issues.
btadlock1
Guest
I get it...I was wrong.
I've acknowledged that I was wrong, but evidently, I need to say it again. I was wrong when I said that it might make a difference if the physician is associated with more than one practice, and I am truly sorry if it caused any confusion. It doesn't make a difference if the doctor is billing under the same information (individual, group, or otherwise) from the last visit or not; if they have personally provided professional services to the patient in the past 3 years, the visit is established.
I would like to point out, though, that Medicare's requirements are slightly different than CPT's. It's probably not applicable to this particular situation, but as Pam mentioned, a lot of people read these forums to answer their own questions. For the benefit of those readers, keep in mind that the professional service must be a face-to-face service, for it to change the patient's designation from 'new' to 'established', if they're a Medicare patient. See the AAFP's article above...
"A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate."
I've acknowledged that I was wrong, but evidently, I need to say it again. I was wrong when I said that it might make a difference if the physician is associated with more than one practice, and I am truly sorry if it caused any confusion. It doesn't make a difference if the doctor is billing under the same information (individual, group, or otherwise) from the last visit or not; if they have personally provided professional services to the patient in the past 3 years, the visit is established.
I would like to point out, though, that Medicare's requirements are slightly different than CPT's. It's probably not applicable to this particular situation, but as Pam mentioned, a lot of people read these forums to answer their own questions. For the benefit of those readers, keep in mind that the professional service must be a face-to-face service, for it to change the patient's designation from 'new' to 'established', if they're a Medicare patient. See the AAFP's article above...
"A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate."
I was not trying to prove you are wrong
I was just trying to clarify the info for myself and all others. I dont want you to think you were wrong, we were debating to get the right answer and we got it (and a lot of extra usefull information). thanks for all your info, It was a pleasure "arguing" with you
btadlock1
Guest
No worries - I was wrong!
I'm glad that I was corrected on it, because I'd hate to give anyone bad information. It took me a couple of posts to realize I had been mistaken (actually, your post was the one that made go back and re-read what I'd said), but I'll be the first to admit when I make a mistake. It just seemed like maybe it wasn't clear that I had corrected myself to everyone (I was probably just being too sensitive).I totally understand your desire to debate - read a few of the threads I've posted in, and you'll see that I'm the exact same way. I don't (always) argue because I think I'm right; usually, I'm not sure if I'm right or wrong, and I'm just trying to pinpoint where I've got a flaw in my logic. The easiest way for me to do that, is to explain all of my logic, step-by-step, and that's perceived as 'arguing' to most people. It doesn't bother me to be wrong every once in a while...
It's a learning opportunity - you learn a lot more from your mistakes, than from your successes; I can promise you that I won't be mistaken on this issue again.
No worries - I was wrong! I'm glad that I was corrected on it, because I'd hate to give anyone bad information. It took me a couple of posts to realize I had been mistaken (actually, your post was the one that made go back and re-read what I'd said), but I'll be the first to admit when I make a mistake. It just seemed like maybe it wasn't clear that I had corrected myself to everyone (I was probably just being too sensitive
I totally understand your desire to debate - read a few of the threads I've posted in, and you'll see that I'm the exact same way. I don't (always) argue because I think I'm right; usually, I'm not sure if I'm right or wrong, and I'm just trying to pinpoint where I've got a flaw in my logic. The easiest way for me to do that, is to explain all of my logic, step-by-step, and that's perceived as 'arguing' to most people. It doesn't bother me to be wrong every once in a while...
It's a learning opportunity - you learn a lot more from your mistakes, than from your successes; I can promise you that I won't be mistaken on this issue again.
Im glad you did not get mad. To me, ladies are always right even if they are wrong so I hope I did not hurt your fillings