Wiki New Pt vs Existing Pt

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janice.davis@lpnt.net

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Family practice, NP new to our group, previously worked as an NP in an ER that our group is not affiliated with, saw pt in that ER. NP leaves employment with that facility. Same patient schedules to see the same NP who is now employed with our group. Is this patient a new patient or an established patient?
 
Established patient as the NP had a face to face visit with the patient already (if it was within the past 3 years). Some may argue that point in that you "could" bill a new E/M due to the prior was ED (no new or est.) and the EIN and NPI (group) would be different, however the patient was established to the provider. The group or employment doesn't matter, it matters that the NP saw the patient face to face already. Would a new E/M possibly get paid if you billed it under the new group? Probably. Is that correct? No.

Example MAC/CMS decision tree: https://med.noridianmedicare.com/web/jeb/specialties/em/new-vs-established-patient-decision-tree
CMS IOM: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
30.6.7 - Payment for Office or Other Outpatient Evaluation andManagement (E/M) Visits (Codes 99202 - 99215)(Rev. 12461; Issued:01-18-24; Effective:01-01-24 Implementation: 02-19-24) A. Definition of New Patient for Selection of E/M Visit Code Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 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.


There is a decision tree in the CPT book.
 
Another question related to new vs established.

I am in an internal medicine group practice (Practice A). Another practice in town (Practice B) closed and several providers from Practice B joined Practice A. Practice A will be taking on many patients from Practice B. My interpretation of the rule is that the previous Practice B providers will bill as established any patients that they have seen in the previous three years. However, providers of Practice A will bill as new patients the former patients of Practice B. And the former Practice B providers will bill as new patients any previous Practice B patients that they have not seen in the previous three years.

Some of our billing personnel are arguing that all patients from Practice B should be billed as established patients when they are seen in Practice A.

Who is correct?

I think the answer might be different if Practice A had purchased or merged with Practice B. (This did not happen).

Thanks for any input.
 
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davidinasheville said:
Another question related to new vs established.

I am in an internal medicine group practice (Practice A). Another practice in town (Practice B) closed and several providers from Practice B joined Practice A. Practice A will be taking on many patients from Practice B. My interpretation of the rule is that the previous Practice B providers will bill as established any patients that they have seen in the previous three years. However, providers of Practice A will bill as new patients the former patients of Practice B. And the former Practice B providers will bill as new patients any previous Practice B patients that they have not seen in the previous three years.

Some of our billing personnel are arguing that all patients from Practice B should be billed as established patients when they are seen in Practice A.

Who is correct?

I think the answer might be different if Practice A had purchased or merged with Practice B. (This did not happen).

Thanks for any input.
Click to expand...
The same idea would apply as I explained above. It is to the person/provider not to the group or practice. However, this can sometimes get sticky. I can see why the billing folks may want to do them all as established, and depending on the group size, etc. I might agree with them. If it is a very large group, things can get really confusing and messy when trying to figure out new versus established so they may want to do established for the sake of speed and to avoid denials and rejections. You are going to have multiple different scenarios when it comes to this. Who is going to figure out whether to bill new or established? Do you have providers, coders and/or billing staff that really understand new vs. established and how to do it correctly the first time? Do you want to deal with lots of denials and/or rejections? Are there NPPs involved too? How big is the group? Are all the providers credentialed the same way (taxonomy?) Does the payer the claim is being billed to recognize subspecialty or do they only look at Tax ID and/or group NPI? Does the payer follow CPT or CMS when it comes to new vs. established? It's messy.

Any patient that the Practice B provider has seen in the past three years, regardless of location or practice, would be established to them at Practice A.
If a different provider of the same specialty and subspecialty in Practice A sees that patient, they would also be established to them because they are the same exact specialty and subspecialty in the same group (now) as the Practice B one.
If the patient has not been seen by any provider from Practice A or B in the past 3 years they would be new.
 
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