Wiki Multi-Specialty Group New Pt. vs. Est. Pt.

[Stefanie]

I just resigned from my Coding Manager position due to a coding policy change that I didn't believe was ethical or legal. I actually didn't get the chance for any due diligence, policy changed, follow it or find another job....


The practice had over 5 specialties, OB/Gyn, Peds, IM, FP, URO, ENT, GI, which shared the same medical record. We had always followed the CPT guidelines about New Patient's, 3 years, same specialty or subspecialty of same group... We would code New Patients for each specialty listed above if the patient had NOT seen that specific specialty for over 3 years, even if they had seen a different specialty a week before... Policy was changed to redefine some specific specialties in the group to PCPs.. (IM, FP, Peds), policy dictated that if a patient had seen any one of these specialties in the past 3 years, the coding was to be established. I disagreed. There are mutliple scenario's that would make this a hot mess.

This policy was presented due to patient complaints of getting "charged" for a new patient visit when they were established patient's in the practice, assuming they were charged more money for a new ptaient charge. I tried to explain to adminstration that a New Patient code does not necessary mean a higher charge, due to DG on New vs. Est. Adminstration called a consulting firm who said it was okay to implement policy due to RAC and AMA having issue with New Patient vs. Established. I disagreed.

So my question is this.... what is your opinion. If you have documentation to support/or not, the policy I would absolutely love to have it.

Your input and expert advice is very much appreciated.

 

[mcnaryk]

I just resigned from my Coding Manager position due to a coding policy change that I didn't believe was ethical or legal. I actually didn't get the chance for any due diligence, policy changed, follow it or find another job....


The practice had over 5 specialties, OB/Gyn, Peds, IM, FP, URO, ENT, GI, which shared the same medical record. We had always followed the CPT guidelines about New Patient's, 3 years, same specialty or subspecialty of same group... We would code New Patients for each specialty listed above if the patient had NOT seen that specific specialty for over 3 years, even if they had seen a different specialty a week before... Policy was changed to redefine some specific specialties in the group to PCPs.. (IM, FP, Peds), policy dictated that if a patient had seen any one of these specialties in the past 3 years, the coding was to be established. I disagreed. There are mutliple scenario's that would make this a hot mess.

This policy was presented due to patient complaints of getting "charged" for a new patient visit when they were established patient's in the practice, assuming they were charged more money for a new ptaient charge. I tried to explain to adminstration that a New Patient code does not necessary mean a higher charge, due to DG on New vs. Est. Adminstration called a consulting firm who said it was okay to implement policy due to RAC and AMA having issue with New Patient vs. Established. I disagreed.

So my question is this.... what is your opinion. If you have documentation to support/or not, the policy I would absolutely love to have it.

Your input and expert advice is very much appreciated.

For what it's worth Stefanie, I agree with you and I would've billed those patients the exact same way. I wish I had documentation to help back us up. CPT clearly states a new patients is one that has not received professional services from the physician or another physician of the EXACT same specialty AND subspecialty in the last 3 years. So, if patient sees Dr. K as their primary care for a cold one week, then comes back a month later as a pulmonary patient seeing Dr. S-same office, same group, but different specialty-then Dr. S's visit I would bill as a new patient. I am sorry your situation was so bad that you felt you had to resign-but it would've been really hard for me to stay too, feeling that unethical practices were going on. Best of luck to you!

 

[Colliemom]

What would be the benefit for the specialist? Why wouldn't he/she bill the new patient visit, if the patient had never been seen by the specialist and had only been previously seen by the internal medicine physician? Is this only to keep the patients happy?

 

[mhstrauss]

Sounds like it was to keep the patients happy, so that they would not complain about the higher charge. In reality, and of course this would depend on their plan benefits, if they have a copay, as opposed to deductible or coinsurance, most of them probably wouldn't even know the difference. Even if they did dispute the "new patient" code, a simple explanation of the new patient guidelines would probably appease most. A sticky situation, indeed. I can maybe see the consultant's point of view, with erring on the side of caution to avoid RAC audits. But the fact remains, if you are compliantly following new patient coding, you really have nothing to worry about, and the doctors are missing out on some possible big bucks!