Part B Insider (Multispecialty) Coding Alert

Published on Wed Jan 16, 2008 PDF

But 3-year rule applies in most other situations

Myth: Medicare's -three-year rule,- which designates patients as new or established, overrides all other Medicare guidance, so you must use it in every situation.

Reality: If the patient has been to the practice within the last three years, he may still qualify as a -new- patient under Medicare guidelines, depending on which specialist he sees in the practice.

As most practices know, if the physician, or any physician of the same specialty billing under a common group number, has never seen a patient before, you should automatically categorize that patient as -new,- which means you can report the new patient E/M codes (99201-99205 for outpatients). And if the same physician (or, once again, any physician of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient new from a billing and coding standpoint.

Remember: If the patient presents to one orthopedist in the practice for a hip problem in July and presents to another orthopedist in the same practice for a knee problem in August, the patient is still -established.- New problems don't allow you to bill the patient as -new.- In fact, even if your practice maintains two offices on separate sides of town, you should still bill the patient as -established- if he sees another physician from the same specialty within the same practice during the three-year period.

Here's the exception: When physicians of different specialties see the same patient within the same 36-month period, the usual -new vs. established- rules do not apply. -If a subspecialist has a specialist distinction that is different from that of the physician who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient,- the June 1999 CPT Assistant states.

For example: -If a patient presents to the primary care physician (PCP) under taxpayer identification number (TIN) 0000000 and the PCP refers the patient to the podiatrist who is billing under TIN 0000000 and the patient has never seen the podiatrist before, then the podiatrist can bill a new patient code,- says Anne Garrity of Alpine Family Physicians. 

-We have family practitioners, internists, pediatricians, orthopedists, general surgeons and ob-gyns, all billing under the same tax ID and haven't had a problem,- says Christy Neff, RMC, billing specialist with Witham Physicians.

Potential snag: A problem could arise if one of the physicians in your practice  has credentialed with Medicare as a different specialty than he is actually practicing under. For example, if the physician credentials with Medicare as an internal medicine physician when he is in actuality an endocrinologist, Medicare will deny services that this physician bills as -new patient- if the patient has seen an internist within the same practice during the three-year period. In this situation, you should ask Medicare to change the physician's specialty designation. 

Example: An orthopedic surgeon sees a patient in 2005 for a total knee replacement. In early 2007, the same patient sees a hand surgeon (a member of the same multispecialty practice) for an office E/M service regarding a ganglion cyst in the wrist.

If the hand surgeon is registered with the insurer under the hand surgery specialty (code 40 for Medicare) and not the orthopedic surgery specialty number (code 20 for Medicare), you can report the hand surgeon's initial visit with the patient using the new patient codes.

Tip: These guidelines also apply to a new physician and any patients he sees prior to joining your practice. If the new physician has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.