What Is Time Lapse Before You Code as New Patient Again

Billing for new patients requires three key elements and a thorough knowledge of the rules.

A persistent concern when reporting evaluation and direction (East/Grand) services is determining whether a an individual is a new patient to the practice or already established. New patient codes carry higher relative value units (RVUs), and for that reason are consistently nether the watchful heart of payers, who are quick to deny unsubstantiated claims. Here are some guidelines that volition ensure your E/M coding holds up to claims review.

Be Certain New vs. Established Applies

Not all E/M codes fall under the new vs. established categories. For example, in the emergency department (ED), the patient is always new and the provider is always expected to certificate the patient'south history in the medical record.

In the office setting, patients see their provider routinely. The provider knows (or can quickly obtain from the medical record) the patient'due south history to manage their chronic weather condition, also as brand medical decisions on new problems.

A provider seeing a patient for the first time may not accept the benefit of knowing the patient's history. Even if the provider tin can access the patient'due south medical tape, they will probably ask more questions.

Who Is a New Patient?

The definition of a "new" patient is given in the CPT® lawmaking volume:

A new patient is one who has not received any professional services from the physician/qualified health intendance professional person or another physician/qualified health intendance professional of the verbal same specialty and subspecialty who belongs to the aforementioned group practice, within the past 3 years.

In improver to this definition, the Centers for Medicare & Medicaid Services (CMS) adds in Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7):

An interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absenteeism of an E/M service or other face-to-face service with the patient does not impact the designation of a new patient.

Let'southward break down the iii key components that brand upward the new patient definition:

Professional Service: When doc coders see this, we automatically recollect of modifier 26 Professional services. This leads us to think that if the provider bills a claim for radiology or labs, and sees the patient confront to face, an established patient office visit must be billed. This is non true, per the same CMS guidance. If the provider has never seen the patient face to face, a new patient code should be billed.

Example: A patient presents to the ED with chest pain. The ED physician orders an electrocardiogram (EKG), which is interpreted past the cardiologist on telephone call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. The patient is sent home and asked to follow upward with the cardiologist next week for coronary artery affliction. At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, but did not come across the patient face up to face up.

Three-year dominion: The general dominion to make up one's mind if a patient is new" is that a previous, contiguous service (if any) must have occurred at least three years from the engagement of service. Some payers may take different guidelines, such as using the month of their previous visit, instead of the mean solar day.

Example: A patient is seen on Nov. 1, 2014. He moves abroad, merely returns to see the provider on November. 2, 2017. Because it has been three years since the date of service, the provider tin nib a new patient East/M code.

Different specialty/subspecialty within the same group: This area causes the almost confusion. For Medicare patients, you tin can utilise the National Provider Identifier (NPI) registry to come across what specialty the dr.'s taxonomy is registered under. For payers, this usually is determined by the way the provider was credentialed.

Those who are office of the credentialing procedure must understand how important it is to get the provider enrolled with the payer correctly. Denials volition ensue if this is not washed correctly.

New to Whom?

Problems begin when doctors switch practices, send patients to mid-levels, and cantankerous-cover for each other. Here are some examples of these situations:

• If a doctor changes practices and takes his patients with him, the provider may want to beak the patient equally new based on the new tax ID. This is incorrect. The taxation ID does not matter. The provider has already seen these patients and has established a history. He cannot bill a new patient code just considering he's billing in a unlike group.
• If a doctor of medicine (Md) or doctor of osteopathy sends a patient to a mid-level provider (i.e., nurse practitioner (NP) or physician assistant (PA)) and the visit does not fall under incident-to, the NP or PA could bill a new patient code if they are a dissimilar specialty with different taxonomy codes. If the Doc is a family exercise provider and the NP sees hematology patients, for case, the specialty is dissimilar and a new patient code can exist billed. But if the NP is also considered family practice, it would non be appropriate to bill a new patient code.
• If 1 provider is covering for some other, the covering provider must bill the same code category that the "regular" provider would have billed, even if they are a different specialty. For example, a patient's regular physician is on vacation, and then she sees the internal medicine provider who is covering for the family practice dr.. The internist must bill an established patient code because that is what the family do dr. would have billed.

Know the Exceptions

In that location are some exceptions to the rules. For example, some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient code, even if they accept seen the patient for years prior to her becoming significant. Medicare considers hospitalists and internal medicine providers the same specialty, even though they take different taxonomy numbers.

Know When to Appeal

If a claim is denied, wait at the medical record to see if the patient has been seen in the by 3 years past your group. If so, check to meet if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings past checking the NPI website to run across if the providers are registered with the aforementioned taxonomy ID. If it's a commercial insurance programme, check with the credentialing department, or phone call the payer, to meet how the provider is registered. If your inquiry doesn't substantiate the denial, ship an appeal.

Run across too "Navigate the New vs. Established Patient Decision Tree."

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Resource
Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.vi.7)

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Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, is coding squad leader at MedKoder in Hannibal, Mo. She has more than 15 years of experience in multiple areas of healthcare including auditing and compliance. Cox has been certified since 2002 and is treasurer of the Quincy, Ill./Hannibal, Mo., local chapter. She is the Region v AAPC National Advisory Board representative.

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Source: https://www.aapc.com/blog/41276-new-vs-established-patients-whos-new-to-you/

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