Wiki New vs Established Patient

[namitachadha]

If a patient has been seen by a Family Practice provider (charged a new patient E&M) and is referred to an Internal Medicine provider within the same clinic practice, can we charge a new patient E&M for the Internal Medicine provider? Or would it be considered established because the patient has already seen an FP provider? IM & FP providers have separate taxonomy codes.

 

[trarut]

There is guidance and a decision tree in the E/M guidelines in the CPT book to help with this. Same practice, different specialty is a new patient for the initial visit. Or consult if the documentation requirements are fulfilled.

My practical experience with this says payers will usually accept a consult but a new patient code will usually deny and need to be appealed. The claims processing system looks at the Group Tax ID on the claim form, not the provider taxonomy, then the new patient claim edits will be applied.

 

[dtricia]

per Noridian the new patient 3 year rule applies to providers with the same TIN.