Wiki Veinpuncture and New Patient E/M

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jessicawrenn

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Hi! Our office has new patients schedule for fasting lab work and then schedule for a later date for a new patient appointment. This way, our office has their lab results back to discuss a treatment plan at the new patient appointment. On lab work appointments, no E/Ms are billed, only the veinpuncture and the appropriate lab tests. For the new patient office visit, a new patient E/M code is billed.

I received a letter today where insurance is trying to recoup payment for the new patient E/M stating that patient is not new, but established. These patients are new to the practice and have not been seen by a provider! Per my code books, a new patient E/M is correct. Have any of you encountered this before? What's the correct answer? Thanks in advance!
 
I'm assuming the insurance company feels a relationship has been established since your Physician has ordered and billed for lab services. The patient is no longer considered "new" to the practice. I have never experienced this but I'm certain that because they see a service has been provided (venipuncture and lab tests), they feel a relationship has been established and this patient is no longer new to the practice.
 
Personally, I would appeal their decision. The patient actually hasn't had an "evaluation and management" visit yet, so the new patient code is applicable. I worked at a PCP office for several years and never had any trouble with such.

Good luck!
Lena
 
Unfortunately, the payer is correct. The venipuncture is a face-to-face service, which prevents your MD from billing a new patient visit when the patient returns for initial E/M/results. The CPT guideline is that if any face-to-face service (not just E/M services) is performed, you cannot bill a new patient visit for that provider/dept for the next 3 years.
 
I, respectfully, disagree

mhstrauss said:
Unfortunately, the payer is correct. The venipuncture is a face-to-face service, which prevents your MD from billing a new patient visit when the patient returns for initial E/M/results. The CPT guideline is that if any face-to-face service (not just E/M services) is performed, you cannot bill a new patient visit for that provider/dept for the next 3 years.
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I, respectfully, disagree.

the venipuncture is NOT face-to-face with the provider.

per CPT guidelines:
"Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s)."

a phlebotomist cannot "report an e/m service", therefore this would not disqualify a patient from being considered "new".

having said that, we strongly encourage our providers to see the patient before ordering labs and it is very rare in our practice for a patient to have labs before being seen by the provider.

:)
 
You might seek assistance from the AMA CPT staff on this. A similar question about reading of x-rays was answered in CPT Assistant of October 2011 that used the definition of face-to-face time to explain why the patient would be new even if the physician had previously provided the x-ray interpretation and report. I don't believe that clinical staff services would meet the face-to-face professional service definition.
 
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