Wiki Multi-Specialty E/M coding question...

[ANDREEAMANN]

A patient has been seen by her oncologist, who refers her to the radiologist of the same practice group. The patient would be coded as a new patient for the radiologist...correct? My logic is because it is of a different specialty and the radiologist has never treated the patient before. But I am 2nd guessing myself because the physician are in the same practice group. Some insight would be greatly appreciated.

 

[analu]

I am pretty sure that if the patient is being seen by a provider with a different specialty the visit can be billed as a new patient visit. I apologize if I didn’t reply in the correct format, this is the first time I reply to a post

 

[Pathos]

A patient has been seen by her oncologist, who refers her to the radiologist of the same practice group. The patient would be coded as a new patient for the radiologist...correct? My logic is because it is of a different specialty and the radiologist has never treated the patient before. But I am 2nd guessing myself because the physician are in the same practice group. Some insight would be greatly appreciated.

Hello,

CMS states:

"Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years."

If the patient hasn't seen either the oncologist and the radiologist with the 3 year time period, or another provider with the same physician specialty (other oncologist and radiologist within their group), then the patient is considered a New Patient. Since the oncologist and radiologist are considered different specialties, then you do not have to worry about those two visits as they are unrelated to each other when determining New vs. Established.


Sources:

CMS Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners - 30.6.7
Noridian - MAC
CGS - MAC
Palmetto - GBA

 

[liloe517]

It has been my experience with a muti-specialty surgical group that if the claims are being billed under the same tax ID number then only one new patient code can be billed within a three year period. I have had a patient see our vascular surgeon and then see our colorectal surgeon and a NP code be denied for the second because they are under the same tax ID number.