Payers Identify “New Patient” Claims Paid Improperly

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  • December 2, 2013
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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.
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, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

No Responses 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.