Wiki New or Established Patient?-We have a unique

Create Wiki
S

srohlmeier

Guest
Messages
19
Location
Northeast Kansas Chapter
Best answers
0
We have a unique situation. Our clinic has a general medicine area and a GYN area. The GYN area used to be staffed by a GYN specialist. She is now gone and the GYN area is staffed by a physician who is an MD but not a GYN specialist. She also sometimes works in the general medicine area. I am guessing that since she is not a GYN "specialist" any patient that she or any other physician has seen in general medicine area would be an established patient. Am I correct? I would appreciate any input. Thanks, Sharon Rohlmeier
 
I'm interested in an answer to your question as well. I know the window is you can bill a new patient every 3 years, but I'm curious do your physicians work under the same TAX ID?

I know for example when our physician sees a patient in the hospital then schedules a follow-up in the office we have to bill an established patient because insurance will reject these claims if we bill as a new patient. They basically saying "Hey you seen this patient in the hospital and done his/her H&P therefore they are not a new patient to you"

My follow-up question to your question is "Does a multi-physician/specialty group have to bill as an established patient though patient A is seen by the internist in the practice then sees the GYN of the practice on another visit?" "Is it taxonomy code related that causes these edits to take place?" edit being can't bill for a new patient code within 3 years, or is it strictly NPI related?

I'm ASSUMING, she will have to bill as an established patient strictly due to being the same specialty,....I'd love for someone to verify this please!!
 
If the providers are credentialed the same then the patient is established. If they are credentialed in different specialties then they are new. The three year rule applies though.
 
New Vs Established

A new patient has NOT received professional services (face to face) either from the same physician, or another physician of the same practice, same specialty within the last three years.

All other situations are considered an established patient.

See definitions in the E/M services guidelines of your CPT manual for reference.

So if the general medicine and GYN are within the same practice, then yes, they would be established patients. That is my interpretation at least.

This is per HCPRO from my advanced E/M class. Hope it helps!
 
Last edited:
I'm finding that it varies a bit from payer to payer how they determine what a provider's specialty is. The Medicare contractors seem to use the specialty that is designated on the provider enrollment form, while commercial payers tend to go with the taxonomy code that is attached to the NPI number. Makes for quite of bit of confusion in this area.
 
You must log in or register to reply here.
Top