Wiki E&M Guidelines New Pt vs. Est Pt.

[lindseyhulley]

I am aware of the "3 year" rule for E&M decision making. I was told by my instructor in school that if a patient switches to another insurance company( Blue Cross to UHC) that we can report 99202, 99203 etc. I have a patient that was recently in an accident, and she has been treating with us. We are now submitting to her Med Pay. I billed this as an established patient visit because I haven't seen anything in E&M guidelines that supports what my teacher said. I was wondering if anyone could shed some light on this for me? Thanks so much!!

 

[mhstrauss]

I am aware of the "3 year" rule for E&M decision making. I was told by my instructor in school that if a patient switches to another insurance company( Blue Cross to UHC) that we can report 99202, 99203 etc. I have a patient that was recently in an accident, and she has been treating with us. We are now submitting to her Med Pay. I billed this as an established patient visit because I haven't seen anything in E&M guidelines that supports what my teacher said. I was wondering if anyone could shed some light on this for me? Thanks so much!!

Your teacher is incorrect. Change of payer is totally irrelevant to new vs established guidelines. The new payer may not deny the claim, because they don't have claims history of previous E/M visits with that provider, but it is still fraudulent, per AMA guidelines.

 

[lindseyhulley]

I knew it!!

Okay then I made the right call. Thanks for confirming

 

[jdibble]

Your teacher is incorrect. Change of payer is totally irrelevant to new vs established guidelines. The new payer may not deny the claim, because they don't have claims history of previous E/M visits with that provider, but it is still fraudulent, per AMA guidelines.

I agree! Change of payer does not change the patient status. The status is dependent on whether the patient has seen a specific provider or group within the 3 year period. For example, if the physician leaves one practice and moves to another practice and the patient follows him to that practice, the patient is still considered an established patient because they had been seen by that physician within the 3 year time frame.