Wiki New Patient

[slivingston]

I hope someone has heard this before or can direct me to documentaton that rebutts this.

I have a provider who wants to bill a New Patient visit on a patient he saw 1.5 years ago. He states because the patient 'transfered' their care to a different provider (at a different office in no way associated with ours) and is now establishing with him again this qualifies them as a new patient.

I cannot find anything relating to new patients and the transfer of care back to a provider within the 3 year period. Has anyone heard of this or does anyone have documentaton that speficialy rebutts this transfer issue?

Any help is greatly appreciated.

 

[LLovett]

Your provider is incorrect

The E/M guidelines in the front of your CPT book are very clear, transfer of care or not, if the patient has been seen by that provider or a provider of the same specialty in the same group within 3 years they are are established.

There is no consideration of transfer of care, change of group (when it is the same individual provider that saw the patient), change of insurance, or anything else. It is based on the provider and time.

Billing out a new patient visit when the patient is established will either result in a rejection (which would be appropriate) or payment that would be incorrect and due to the submission of a false claim. This is an area of interest of both CMS and the OIG.

Good luck,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[ollielooya]

This is probably one of those cases where your provider "heard somewhere" or "heard something" that this patient could be considered a new patient. I often wonder what doctors talk about or share with each other when they get together. Whether or not that be the case, Laura is correct and if you bill as a new patient, most likely will be rejected. I'm sure your doctor would not be want to be caught in the cross-hairs of an audit for this type of billing.