Wiki New patient vs Established patient

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574coding

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HI,
We bill for a medical group that has multi specialty providers in it. We are having issues with New Patient denials.

Does anyone have any tricks on how to appeal the denials? The insurance company seems to be using the group tax ID number to process the claim and not the NPI number.

I also do not know where to find out the type of provider fall in the same specialty - such as does anesthesia and pain management...we have ortho and one provider that is a spine specialist....

Its been difficult to appeal this and I would be great to see if any one has any ideas or places to look for more information.

Just following the decision tree in the CPT book is not helping.

Thanks
 
Hello 574coding,

I was involved in a similar article about the same question and here is the answer we got.

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!
 
Same Group=Established

I agree; We have several providers in our facility. A patient that was seen by Provider 1 & then returns to see Provider 2 within 3 years is considered an established patient. We are also a CAH with a RHC attached. So if the patient sees Provider 1 in our ER then comes to see Provider 2 in the clinic, again, they are an established patient. They have to be new to the facility, not so much the specific provider.
 
574coding said:
HI,
We bill for a medical group that has multi specialty providers in it. We are having issues with New Patient denials.

Does anyone have any tricks on how to appeal the denials? The insurance company seems to be using the group tax ID number to process the claim and not the NPI number.

I also do not know where to find out the type of provider fall in the same specialty - such as does anesthesia and pain management...we have ortho and one provider that is a spine specialist....

Its been difficult to appeal this and I would be great to see if any one has any ideas or places to look for more information.

Just following the decision tree in the CPT book is not helping.

Thanks
Click to expand...


You can find out how each provider is registered by searching them on the NPPES site:

https://nppes.cms.hhs.gov/NPPESRegistry/NPIRegistrySearch.do?subAction=reset&searchType=ind

It will show their primary specialty and subspecialty.

We have had the same issue with a couple of our smaller payers. Appealed with the printout showing each physician's taxonomy, and a copy of the page from the CPT book with the New Patient guidelines. Most were paid after appealing.

HTH!
 
It could just be the insurance company has the wrong specialty and sub specialty. I know i've seen this issue with the payer I work for. Somehow gets listed as Internal Medicine but missing the real specialty. Have you called to see what they list for specialty and subspecialty in their claims system?
 
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