NPP Visits Can Affect “New vs. Established” Status

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  • September 1, 2012
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By G.J. Verhovshek, MA, CPC
A letter to the editor in the July 2012 Coding Edge, (“New vs. Established Patient Rule Applies to Physicians Only,” page 10) asked how the “new vs. established patient” rule applies to visits by nurse practitioners (NP). In response, Coding Edge editors—specifically, this editor—responded that an NP technically would not count as a physician under the new vs. established patient rule. And, if an NP within the practice had provided face-to-face services within the previous three years, but no physician had done so, the patient would be “new” to the group.
As it turns out, my advice was wrong.
In fact, if an NP or other non-physician practitioner (NPP) within a practice provides a face-to-face service for a patient within a three-year period, the patient would be established with the practice, regardless of whether a physician had also seen the patient during the same time.
While endeavoring to correct my mistake, I was reminded of two very important lessons: 1) A coder can never stop learning; and 2) As coders, our greatest resource is one another.
School Is in Session
Shortly after the July issue was mailed, Jules Enatsky, RT, BSN, CPC-H, sent me an email challenging the advice I had given. “NPs in many rural areas are the primary provider for patients,” he wrote. “If NPs don’t follow the [“new vs. established patient”] rule as it pertains to physicians, what rules would you expect them to follow?”
Mr. Enatsky had a point. I wrote him back, promising I’d look into the matter.
I’ve been a coding educator for nearly a dozen years. I’ve read every word of every year’s CPT® and ICD-9-CM manual since 1999. I’ve poured over thousands upon thousands of the Centers for Medicare & Medicaid Services’ (CMS’) guidelines, again and again, in pursuit of arcane coding knowledge. I can quote chapter and verse from the Medicare Claims Processing Manual. Yet, all that education and all that time invested has made me realize: You can never know it all. There’s just so much to know. So many guidelines leave room for interpretation, or vary by payer. And always, what you need to know is changing, evolving, and expanding. Even after all these years, I’m still just scratching the surface.
I had researched the question of how an NP visit affects a patient’s “new vs. established” status carefully. At least, I thought I had. Clearly, there was more to know. Luckily, I had yet to tap into my single greatest resource: my fellow coders.
The Power of Your Peers
No individual can know it all, but if you are willing to ask for help and share advice of your own, there’s very little you can’t learn when you go to your coding peers for help. We all benefit by sharing our collective knowledge and experience.
I have the advantage of working alongside AAPC National Advisory Board President Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P; AAPC Director of Curriculum Katherine Abel, CPC, CPMA, CPC-I, CMRS; and AAPC Director of Education Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC. I turned to them for help with Mr. Enatsky’s question: Are NPs really “exempt” from the new vs. established patient rules as they apply to physicians?
Ms. Abel answered my email first, summing up her answer by citing Medicare’s definition of a new patient, taken from the Medicare Carriers Manual:
“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.”
“In my opinion,” she continued, “an NPP would be part of the ‘physician group practice’ and would fall under the same guidelines.”
Ms. Jimenez quickly concurred, answering: “With the ongoing changes in CPT® to include the verbiage from physician to include ‘other qualified health care professionals,’ it is safe to say that an NP would fall under the ‘physician group practice.’”
Ms. Stewart made the vote unanimous, reasoning, “When payers adjudicate claims, they look at the tax ID and taxonomy code (per credentialing) of the provider to determine if the patient is new or established … the patient seen previously by the NP would be established.”
I verified the sources and, thanks to the keen eyes and advice of my peers, I was able to identify the problem and find the information I needed to correct my original advice.
Lesson Learned
The next time you run into a tough coding case, remember that coders are curious and always looking to learn something new; nothing could be more suited to the job they face. Coders are also generous with their knowledge and experience, and take as much delight in teaching others as in learning.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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