Wiki New vs Est Patient Visit/PAs

[rchacki]

Two PAs in multi-specialty clinic/same tax id. Each works in a different specialty department. Per Medicare, PAs considered same specialty/same taxonomy. If PA #1 sees patient one year ago and PA #2 sees same patient for first time today, is it a new patient or established patient?

Thank you!

 

[martinni1974]

Established.

A patient is not considered new unless three years has passed since they were last seen by the provider and a bill was submitted to the payer, regardless of tax ID.

The only caveat to this is when using consult codes, they are for a new "condition" in which a patient consult has been requested. PA's typically do not use consult codes as they are specialty neutral and when they do they tend to have a high denial rate.

Good Luck

 

[rthames052006]

Two PAs in multi-specialty clinic/same tax id. Each works in a different specialty department. Per Medicare, PAs considered same specialty/same taxonomy. If PA #1 sees patient one year ago and PA #2 sees same patient for first time today, is it a new patient or established patient?

Thank you!

In this case, you can appeal Medicare's decision by completing a redetermination form. Each PA should have a supervising physician on file and written in their contract agreement. This is the only way you can prove differant specialty. It would be based on what specialty their supervising physician is.

We've had this issue come up several times, too many than I care to remember but we've been successful upon appeal and submitting to Medicare a copy of the PA-s agreement and supervising doc.

Good luck!

 

[Colliemom]

We are about to become a multi-specialty practice, as we are joining with other specialists and internal medicine physicians.

So if our PA's, who see gastroenterology patients, are asked to see a patient for the first time by one of the internal medicine physicians, they cannot bill the visit as new? Even though the patient has never been seen by that speciality?

I thought the rule was:
"a new patient is "a patient who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years."

So wouldn't this mean the patient, referred by the PCP to the Gastroenterology PA, be considered new?

 

[mhstrauss]

We are about to become a multi-specialty practice, as we are joining with other specialists and internal medicine physicians.

So if our PA's, who see gastroenterology patients, are asked to see a patient for the first time by one of the internal medicine physicians, they cannot bill the visit as new? Even though the patient has never been seen by that speciality?

I thought the rule was:
"a new patient is "a patient who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years."

So wouldn't this mean the patient, referred by the PCP to the Gastroenterology PA, be considered new?

I agree with Roxanne above. We have this very same issue, especially since Novitas took over as our MAC last summer.

Colliemom, in the example you are giving, the first time the patient sees the PA under Gastro, it should be considered new, as long as they have not seen any provider under Gastro in your clinic previously. However, due to what Roxanne explained above, you will probably have to appeal to get paid.