Billing a new patient visit when no prior E/Ms billed for last 2 years

ljones88

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I have a question regarding a new patient visit. If we had a dr perform an emergency tracheostomy in the hospital two years ago and then the patient presents to the office for a sinus infection 2 years later, no E/M has ever been billed for this patient and it is within the 3 year mark, would we still have grounds to bill the new patient visit? My instinct is telling me yes cause CMS defines new patient as "A patient who has received no E/M services from the same physician or another physician of the same specialty in the same group within the previous three years."
 

mhstrauss

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I have a question regarding a new patient visit. If we had a dr perform an emergency tracheostomy in the hospital two years ago and then the patient presents to the office for a sinus infection 2 years later, no E/M has ever been billed for this patient and it is within the 3 year mark, would we still have grounds to bill the new patient visit? My instinct is telling me yes cause CMS defines new patient as "A patient who has received no E/M services from the same physician or another physician of the same specialty in the same group within the previous three years."

Where are you getting your CMS info? The true CMS definition is "no face-to-face services"...which could be E/M, surgical procedure, diagnostic procedure that has a face-to-face component, etc. In your example, this should be an established patient, because the physician performed a service within the last 3 years. See link for CMS definition:

https://questions.cms.gov/faq.php?id=5005&faqId=1969
 

mhstrauss

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I was pulling the quote from our MAC, first coast service options, which now has me second guessing my instincts.


Ahhh sorry to discredit them-- I know I certainly rely on my MAC for A LOT of info. Is there a way to contact them for clarification? I know some set their own guidelines with some things, but I can't imagine them changing such a major E/M rule set by the AMA.
 

CodingKing

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I cant find anything on first coast website defining new patient based on E&M alone. I do find links to medicare stating professional service which defined as E&M or face-to-face service (eg, surgical procedure). You sure are close to a persons face when you do an emergency trach and that is a surgical procedure so id say established.
 

mitchellde

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I have read this and then thought about it. So here is a thought to ponder... I am wondering if the general issue here MIGHT be that even though the physician was "face to face" there was really no interaction with the patient. And I believe they may be thinking that face to face really means interactive communication. Since the provider performed an emergency trach, the patient will never have any recollection of this event as there was really no interaction and the provider only performed an emergency trach based on spur of the moment emergency issues. So is that truely then the definition of a "face to face encounter". ....... Just a thought to ponder.
 
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The decision of new vs established isn't based off when an E/M charge was billed; it's a matter of whether or not the patient received any professional services within that 3 years, not specific to E/M services only. The only exception, as mentioned, are services that are not face-to-face (eg, interpretations of labs or an x-ray).

Just because there was no E/M billed out from the prior visit doesn't mean one didn't happen. There's always a possibility that someone overlooked that service and subsequently it didn't get billed. The guidelines are whether or not the patient received services. It's not dependent on whether or not the services were actually billed.

What I'm not seeing here is any elaboration on what specialty or specialties are involved. Are the providers part of the same "group" by definition? If it's the same group and same specialty, then it's established.
 

CodingKing

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I have read this and then thought about it. So here is a thought to ponder... I am wondering if the general issue here MIGHT be that even though the physician was "face to face" there was really no interaction with the patient. And I believe they may be thinking that face to face really means interactive communication. Since the provider performed an emergency trach, the patient will never have any recollection of this event as there was really no interaction and the provider only performed an emergency trach based on spur of the moment emergency issues. So is that truely then the definition of a "face to face encounter". ....... Just a thought to ponder.

That is what i was thinking then i recalled that you can bill an E&M on an unconscious patient. To me if you actually place your hands on the patient it's face to face. Also every surgical procedures has at least a minimal E&M component bundled into it.
 
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