Wiki New vs. Established for Radiology Physician

[TamaraM]

I work for a group of radiologists-- a few times a month one of our radiologists goes to a vascular clinic and sees patients face to face - normally as a consult to see if the are good candidates for procedures such as epidurals of venous ablation.

Any who I have a denial:

I billed 99202 (new pt) and I am being denied for "PAYMENT ADJUSTED BECAUSE NEW PATIENT QUALIFICATIONS WERE NOT MET".... now 2 years ago our office read an ultrasound done on this patient but this is the first time we saw the patient face to face or billed an OV in six years.

Per the CPT book: Distinguishing between new & est. patients, professional services are those face to face services rendered by a physician and reports by a specific CPT code. A new patient is one who as not received any professional services from the physician (or one from same practice) with in the past 3 years.

So my dilemma..... Is this a New Pt Ov b/c we have not seen the pt face to face in over 3 yrs? ...... or...... Is this an est. pt. bc we have billed a prof. component w/in the past 3 yrs?


PLEASE ADVICE

 

[OCD_coder]

Technically you have billed for services within the last 3 years, so the insurance company is correct in that patient is established.

You could appeal it, but good luck.

 

[TamaraM]

So you are in agreement that although we have not had face to face time with the patient, because we have provided professial serivices to the patient, they would be considered established.