In Group Practice, Even a “New” Patient May Be Established

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  • August 4, 2015
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In Group Practice, Even a “New” Patient May Be Established

by John Verhovshek, MA, CPC
If no member of a group practice has provided a professional (i.e., face-to-face) service to a patient within the past three years, the patient is “new,” according to CPT® and Centers for Medicare and Medicaid (CMS) definitions.
For example, Dr. Jones, a new physician in a group of general practitioners, sees a patient, Mr. Smith. Neither Dr. Jones nor any other GP in the group practice has seen Mr. Smith for a professional service in the previous 36 months. In this case, Mr. Smith is a new patient.
Under CMS rules, if the patient has been seen in group practice within the previous 36 months, he or she is “established” to all providers of the same specialty/subspecialty within that group practice, regardless of whether the individual provider previously has seen the patient.
For example, suppose that Mr. Smith sees Dr. Jones, and six months later returns to the group practice and meets with another GP, Dr. Adams. Although Dr. Adams has not personally seen Mr. Smith, previously, Mr. Smith is an established patient, under Medicare guidelines.
If another provider within the group practice has seen the patient within the past three years, but that provider was of a different specialty/subspecialty, you may report a new patient service. For a list of Medicare-recognized physician specialties, visit the CMS website.
For example, let’s now suppose that Dr. Jones belongs to a multi-specialty group practice. After seeing Dr. Jones, Mr. Smith returns to the practice three months later to see an orthopedist, Dr. Bones, who is also a member of the group practice and whom Mr. Smith has not previously seen. Because Dr. Jones (the GP) and Dr. Bones (the orthopedist) are of different specialties, and because Dr. Bones has not provided a service to Mr. Smith within the previous 36 months, Mr. Smith is a “new” patient for Dr. Bones but an “established” patient for Dr. Jones, in the same group practice.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

No Responses to “In Group Practice, Even a “New” Patient May Be Established”

  1. Maria Valladares, RN, BSN, CPC, CPMA, CEMC, COC says:

    What if Dr. Bones also moonlights at an acute-care clinic XYZ, where he evaluated the patient and referred the patient to the group practice ABC. Even though the patient has never set foot in group practice ABC before, he is actually an established patient of Dr. Bones. Is the patient an established patient of group practice ABC also?

  2. Barbara A. Love CPC, COC says:

    Well illustrated.
    Barbara Love, CPC, COC

  3. Karen Hill, CPC, CPB, CPMA says:

    I have one other scenario that I’d like get comment on. I have a provider who is leaving a group practice and join our group. All providers are of the same specialty. Our new provider is not “bringing” his patients with him, however, if a patient from his previous practice comes to see him at his new practice, is the patient still considered established? I presume that, if this patient saw someone else in the practice instead of the new provider, they would definitely be new. TIA.

  4. Craig says:

    Does it matter if the group all bills under the same tax ID number? Thanks!