Patient May Be “New” If Seen by Different Specialists within the Practice

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.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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