Wiki New Patient E&M under 3-year rule

[shelli.hester@pehp.org]

Per the CPT book, the patient cannot receive any "professional" services from the physician/qualified health care professional of the exact same specialty and subspecialty in the same group practice within the past three years.

If the patient has only received allergy injections in the last 4 years in a specific office would it be appropriate to allow a new patient E&M? Or, are the allergy injections considered a professional service even if provided by a nurse or PA?

The member was a new patient to their office back on 11/5/13, they had surgery and then started going there for allergy injections, done by the PA and billed under the MD’s name, which is typical. They had established visits on 4/21/14, 7/8/14 and for various complaints, with different doctors in the practice and the new patient visit was billed on 2/2/18 when they presented for an earache. The patient wasn’t seen by the physician, ever, until that date. So technically, although the last allergy injection billed under this physician was on 7/29/16, they haven’t been seen by a physician in the office since 7/8/14 with exception the allergy injections provided by the PA, and they should be allowed the visit.

Should the new patient exam be allowed in this case?

 

[Pam Warren]

No, those are considered professional services, even though they are billed incident-to (which by the way, requires onging physician involvement in the patient's established treatment plan). Established patient.

 

[mitchellde]

The concern here is if the physician has never examined this patient ever, then the visits by the PA should have never been billed using that providers NPI number. For incident -to apply the physician must examine the patient for the same diagnosis as the current visit and must establish in that note the plan of care for the follow up visits. This could be a huge issue. However if the patient has been examined by a different provider in this practice and is in the same specialty as the provider in question, and that physician established the plan of care... then if the service was billed using this "new" physician NPI due this provider was in the office supervising at the time of the encounter, then all is good, however as Pam indicated the "first " visit with the provider is actually establishes since he was supervising the previous visits.