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AmandaW

AmandaW

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When it comes to a hospital visit, what constitutes a new verses established patient?

If my hospitialist Dr is seeing a patient for the first time but the patient has been admitted before and was seen by another group of the hospital would my patient be new or established?

The patient would be new to my Dr and my hospital 'group' (of hospitialists) but NOT new to the hospital itself. (??)
 
By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years.

http://www.foley.com/files/News/69a...0e-5ea5-4808-bde0-642d8a879c36/rmc11-5-12.pdf

the HHS Office of Inspector General is auditing hospital claims for new and established patients, RMC has learned. The audits focus on billing by some hospital-based outpatient clinics, which may have overcharged Medicare by treating established patients as if they were new patients. OIG may eventually be staring at a recoupment goldmine because most hospital billing systems can’t readily distinguish between new and established patients, experts say.
 
Yeah, I saw that too as I was searching for this answer and then saw something that alluded to the fact that this rule is different when it comes to a hospital setting but then I couldn't find anything else that elaborated on that. So, the patient is new to my 'hospitialist group' but not new to the hospital itself. In that case I've coded them as a new patient, but wondering if I am correct on that.
 
For inpatient hospital and emergency room visits there is no distinction between new and established patients, even if your provider did a consult there is no distinction (99241-99245, 99251-99255). You would only code a new patient if the patient was seen in an "outpatient" setting, i.e. observation (you're not the provider of record and pateint is not formally admitted), outpatient clinic.
 
Since these are hospitalist services, you would have to be careful - if another hospitalist in the group admitted the patient and used 9922x for the initial visit, the remaining visits by the hospitalist groups would be subsequent visits under 9923x. We have had this issue come up as well and used this method.
 
dclark7, sorry didn't clarify that earlier on. The instance in which I'm asking about is indeed outpatient. It's when it's Medicare/BCBS...one that doesn't accept consult codes...and the Dr is doing an outpatient consult.
So, knowing that, would I pick New or Est if the patient has been admitted to the hospital before (not seen by my hospital group) ?

Mntwins29, when you say the remaining visits will be subsequent 9923x you mean just for that hospital stay right? If the patient comes back again and is admitted 8 months later it would be another admit (99221-99223) right?
 
New vs Established

I have a question. My physician works in the sleep clinic as well as neurology. She seen a patient in the sleep clinic and now is wanting to see them in the neurology clinic for a completely separate reason. Is that patient a new patient in Neurology or is it an established patient due to the fact that my physician has seen them prior in the sleep clinic.

Thanks for any help.
Tylene
 
AmandaW said:
dclark7, sorry didn't clarify that earlier on. The instance in which I'm asking about is indeed outpatient. It's when it's Medicare/BCBS...one that doesn't accept consult codes...and the Dr is doing an outpatient consult.
So, knowing that, would I pick New or Est if the patient has been admitted to the hospital before (not seen by my hospital group) ?

Mntwins29, when you say the remaining visits will be subsequent 9923x you mean just for that hospital stay right? If the patient comes back again and is admitted 8 months later it would be another admit (99221-99223) right?
Click to expand...

Yes, that is correct - if the patient is discharged and admitted later, the first encounter after the new admission would be 9922x
 
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