Wiki New VS Established---Behavioral Health

[tonhar35]

Established clients are being referred to prescribers. Prescribers are billing New E/M vs Established. Why? Because this is their first encounter with client. Claims are denying because claims are being billed under same group. The insurance is basically saying client is established. Are these claims denying is error? I don't think they are. However, our higher ups seem to think claims are denying in error. Coding guidelines state that “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” HELP!!!!

 

[Mo Crowder]

Not having all of the information with the denial/remark codes, I would want to know the specialty of your prescribers and the referring providers. Referrals to a different specialty within the group could be a consultation and not a regular office visit if the 3 R's are met (Medicare exception). As you stated, if they are in the same group and same specialty, the clients are not new. If, however, you have psychologists referring to psychiatrists, those are different specialties. In this case, you want to check your taxonomy codes to make sure they are not enrolled incorrectly with the payer.

Let me know if this helps.