Wiki NEW or ESTABLISHED PATIENTS IN A GROUP PRACTICE

[RABBIT2020]

This is a group practice with Obgyn and Maternal Fetal Medicine subspeciality.
Patients are scheduled among the 4 office locations depending on their medical needs.
The doctors circulate among the 4 locations
There is one central EMR with patients database.
Each facility has its own identifying tax id.

Questions:

1. Patient goes to Ultrasound A has a face to face with a MFM specialist for a consult. The following week the patient goes to OB office for an outpatient problem visit with an
obgyn. Is the patient new or established to the obgyn? Why?



2. The Patient is seen at the Gyn office for a procedure by a gyn doctor. She subsequently goes to the Ultrasound site for a scan. A MFM specialist consult (face to face) with her due to an abnormal finding on the scan. Is the patient new or established to the MFM specialist?

3. A patient has ob procedure (amniocentesis) at the ultrasound facility by the MFM specialist. Two weeks later the MFM specialist sees the same patient for a Gestational diabetes at the OB office? Is the service at the ob office billed as a New patient or established patient visit. (consultation is billed with office visit cpt)

3. Just because these offices are at separate locations and have their own separate tax id are they to be considered separate entities?

 

[thomas7331]

You have a relatively confusing situation here, and in these cases I think the answer is going to vary depending on the payer. For example, Medicare does not recognize the MFM specialty, so if these providers are identifying their specialty on the Medicare as OB and both providers are billing the same tax ID, then Medicare will consider the patient established even though your specialties are different (though you could potentially appeal a denial by submitting documentation showing a different subspecialty). Other payers may or may not recognize these as two distinct specialties. Also, payers usually will only consider a patient established after a face-to-face visit, but not if the only thing done was a diagnostic ultrasound, however this can also vary from payer to payer. Lastly, your situation is complicated by providers moving between locations. Assuming they bill under the location's tax ID, then they are actually practicing in different groups. If a patient establishes with a provider in one group, then that patient will remain established with that same provider even if the provider see the patient again in a different location, however, the patient would be new to any different provider under the new tax ID.

So in short, the basic rule is: [a face-to-face (usually E&M) service by the same provider within 3 years] OR [a face-to-face service by a provider with the same tax ID and same specialty within 3 years] = established; otherwise the patient is new. But again, payer rules will vary depending on how they credential your provider and process the claims, so you will probably find there is no perfect formula. Given the complexity of this situation, your practice might find it more cost-effective to establish the patient at their first visit to a provider in any clinic, and keep them established from then on, rather than investing the time trying to figure this out again at every encounter.