Patient May Be “New” If Seen by Different Specialists within the Practice
by John Verhovshek, MA, CPC
Question: If a patient seen at internal medicine then referred to cardio subspecialty within our clinic, is the patient new or established to cardiology?
Answer: A patient is new if he or she has not received a face-to-face, professional service from the provider, or a provider of the same specialty/subspecialty in a group practice, within the previous 36 months.
The Centers for Medicare & Medicaid Services (CMS) advises:
Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. 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.
The cardiologist and internal medicine physician are two different specialties, per CMS; therefore, the patient is new to the cardiologists, assuming that no cardiologists within the group provided the patient a face-to-face service in the previous three years.
Resource: For a list of Medicare-recognized physician specialties, see the Medicare Claims Processing Manual Chapter 26, section 10.8.2.