Payers Identify “New Patient” Claims Paid Improperly

Working within a group practice can alleviate many of the financial headaches encountered in a private practice, but it also can create new challenges—such as keeping track of new versus established patients.

A “new patient” is one who hasn’t received any professional services, such as an evaluation and management (E/M) or other face-to-face service, from a physician or physician group practice of the same specialty within the previous three years.

Evaluation and Management – CEMC

For example: A physician in a radiology group practice provides an E/M service for a patient. The group practice provided diagnostic imaging one year prior, but no E/M or other face-to-face services have been provided to this patient with the past three years. This patient would be considered a new patient.

Per the Medicare Claims Processing Manual, chapter 12, section 30.6.5: “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.” A beneficiary seeing a physician of a different specialty within the same group practice within a three-year period also would not affect his or her “new patient” status.

Fair Warning

Many practices will soon find out just how costly a mistake it can be to claim a new patient E/M visit for an established patient. Effective Oct. 1, 2013, Medicare payers implemented a new edit for checking claims to make sure they aren’t paying for two new patient CPT® codes within a three-year period.

The new patient CPT® codes they will be checking in these edits include 99201-99205, 99324-99328, 99341-99345, 99381-99387, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT® codes is not paid subsequent to payment of a claim with an established patient CPT® code (92012, 92014, 99211-99215, 99334-99337, 99347-99350, 99391-99397).

Payers will be treating such claims as improper payments and will take usual steps to recoup payment. If you haven’t received any such notices of repayment, don’t breath a sigh of relief just yet. Due to the government shutdown in September, payers are back-peddling a bit.

In an E/M general article published Oct. 22 on its website, Palmetto GBA, Part B Medicare administrative contractor for jurisdiction 11, advises providers to follow the usual protocol for appealing claims believed to be incorrectly adjudicated.

Source: MLN Matters® MM8165 Revised

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

One Response to “Payers Identify “New Patient” Claims Paid Improperly”

  1. Ahne Elliott says:

    I am wondering if a patient that is referred to a physician for an inhouse echo by another physician comes and has the echo done in office then is told to f/u with the same physician that performed the test is it should be a new pt or est. pt code.

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