Wiki One doctor, two medical practices

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gstapleton

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Evening:

We have an new Internal Medicine physician that is working for us and another medical practice part time. He bills under different tax id# for each practice and the two practices are not connected in any way.

He had a patient from the other practice come see him in our office. The patient had never been to our office before. It is not clear if the patient will transfer care to our office.

The physician coded a new patient visit.

The CPT states that a new patient is one who has not been received any professional services from the physician or another physician of the same speciality who belongs to the same group practice, within the past 3 years.

This patient had seen the physician just 3 weeks before and this was a follow up visit. I would think this would be an established patient visit. The physician states that because it is a different tax id#, it is a new patient visit.

Is this correct?

Regards,

Denna Stapleton
Denna@san.rr.com
 
yes the physician is correct it would be a new pt because this is a different practice, it can be very confusing but the ins will not pay established because its a new visit under a diff tid. I hope this helps.
 
Established

A new patient is one who has not received ANY face-to-face care from the physician (or another physician of the same specialty, same practice) in the last three years.

This physician HAS seen the patient withint the last three years. Makes no difference if the patient was seen at another practice, in the ER, or at home. The patient has received direct patient care from this physician within the past 3 years, so the patient is ESTABLISHED.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Even if the patient is new to the clinic, they are NOT new to the provider and the visit should be an established visit: provider is the first rung in the hierarchal ladder, then speciality, then health care organization.
 
You might let your provider know that yes this is a new tax ID#, but the physician's NPI# is also on the claim. Therefore, since he has billed under his NPI# within the last three years, this is an established patient.
 
One physician two practices

Thank you all for your replies. Because the physician insisted, I called the insurance carrier. A PPO for a patient not eligible for Medicare. They emphatically stated that the definition of new patient begins with the physician, not the tax id#. They have record of the new patient visit payment under the other clinic 3 weeks ago and they said they would not pay another new patient office visit for the same NPI number. They had no problem paying the established code under a different tax id#. They said that if we had sent in the new patient code, they would have denied it.

I took this back to the physician. He did not like it, but did see the logic of the same NPI.



G Stapleton
 
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