Wiki New patent vs Established Patient

[PCMOS]

I work for an orthopedic surgeon/sports medicine doctor. We recently added a foot/ankle specialist. If the sports medicine doctor refers a patient to the foot/ankle specialist is this billed as EP since in same practice or NP since different specialties?

 

[ellzeycoding]

The CMS and CPT definitions vary slightly.

According to CPT, a new patient is any patient that has not received any professional services from a provider or another member of the provider’s group of the exact same specialty and subspecialty within the past 3 years.

According to CMS, they interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Note: The AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare.


CMS in their Evaluation and Management Services Guide also provides definitions of new and established patients.

"For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.

A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years."


Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

CMS has provided a source of specialty codes and taxonomy codes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf