Wiki new vs established same specialty

[amckay1229@yahoo.com]

I do billing for 3 providers of the same specialty who share office space, share the patients & the charts but have different TINs. The drs think they can bill a new patient ofc visit when they see the other's patient for the first time, because the pt is "new to them" & because they have different TINs. I disagree because they technically are acting as a group practice (though different TINs) and are sharing the patient charts so the history etal is already established. What would be the correct way to bill these visits? New or Established? Thanks for your help!

 

[cingram]

established. They are acting like a group, they are sharing an office suite right? What if an auditor came in would your doctor say "well we share the same suite but we are actually 3 different offices?" I dont think that will fly.

 

[Pauline Newhouse]

I agree!! Unless the pt hasn't been seen for the past three years then they become a new pt to the other provider. It will be denied if billed as a new pt.

 

[tracyp38]

I agree as well. When a patient is seen by one Provider of the group, the patient is Established to all other Providers of the same group for the next 3 years. You cannot bill a New Patient visit if another provider of the group has previously seen the patient within 3 years. Hope this helps.

 

[Naveen Rachagolla]

NPP Visit Affects “New vs. Established” Status

If a non-physician practitioner (NPP)—but not a physician—has seen a patient within the last three years, is the patient new or established?

Although CPT® consistently uses the term “physician” in the context of determining whether a patient should be considered “new” or “established,” most payers—Medicare payers in particular—don't apply that instruction literally. For example, Medicare's definition of a new patient, taken from the Medicare Carriers Manual, instructs:

“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 three years” [emphasis added.]

Because the NPP would be a member of the group practice, if he or she has seen a patient within the past three years, that patient would be established with the group.

The Centers for Medicare & Medicaid Services (CMS) offers even more explicit instructions in its MLN Evaluation and Management Services Guide:

“For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.

“A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

“An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years” [emphasis added].

The bottom line: If the patient has seen an NPP in the practice within the previous three years, you should treat the patient as established.

But remember, a patient is established only if the physician or NPP provides a face-to-face service within the past three years.

“For example,” continues the Medicare Carriers Manual (chapter 12, section 30.6.7), “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.”

 

[Anna Weaver]

This is what our carrier has to say (WPS):

Q3. Our clinic has multiple locations. Our internal medicine specialists are in separate locations with separate charts. Can we bill a new patient visit when the patient sees the physician on Main Street for the first time even though the patient previously saw another physician in our office on 1st Street? The physician on Main Street has never seen the patient before and does not have any notes of previous visits. If we bill both services as new patient services, will we need to worry about any post-payment audits?
A3. Medicare views physicians within the same group with the same specialty as the same person. We determine whether physicians are members of the same group based on the Tax Identification Number. If both locations are under the same Tax ID, then Medicare will deny the second new patient visit procedure code received within the three-year period. There will be no post-payment review of the denied services.

Q7. We have a very large group with different tax numbers. How do we decide new patient versus established patient?
A7. Medicare views physicians within the same group with the same specialty as the same person. A group is comprised of members having the same tax identification number. If there are different tax identification numbers, the physicians are not part of the same group for Medicare billing .