Wiki NEW vs ESTABLISHED MEDICARE PT'S

[KIMBER035]

I have a Dr. that is questioning how we bill a Pt. with Medicare, whom he has seen within the 3 year period, & has coded a different ICD 10 code. He thinks it should be a "New" visit, not an Established visit. I have given him all kinds of info. about the billing of the two, BUT none of the info. I have given him states that putting a different/new complaint (ICD 10 code), will not effect/or effect the rule. Anyone have any suggestions of where I can get that info. in black & white to show him?

 

[sxcoder1]

There wouldn't be anything in black and white because diagnosis coding does not affect whether it's new or established. If it did, then there would be something written in the CPT guidelines. I've never seen anything anyway!

 

[Atonya]

3 year rule for medicare

MEDICARE IS SPECIFIC ON WHAT ESTABLISHES A NEW PATIENT, THE ESTABLISHMENT OF A NEW PATIENT DOES NOT HAVE TO DO WITH THE DIAGNOSIS.
PLEASE SEE BELOW.

30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215) (Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)
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.
B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient
hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

I HOPE THIS HELP