Confusions on Medicare Guidelines

Jody Mortensen

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I have 2 questions concerning Medicare guidelines:

1) The definition of a New patient in the Medicare Claims Processing Manual is: "a patient who has not received any professional services from the physician or physician group practice (same physician specialty) within the previous 3 years. We are receiving a deniel from a third-party payor (citing Medicare guidelines) that the claim is denied at the New patient EM level because the patient has been seen at our facility. It was billed as a new patient EM due to seeing a cardiologist whom the patient had not seen prior or any other cardiologist in that specialty. Wouldn't this be considered a New patient? The concern I am hearing from others is that we submit the bill as a group practice so the cardiologists are considered part of the group. I work at a multispecialty facility. Can anyone can help me clear the confusion on this?

2) Medicare patient is seen in clinic by MD for a rash, who then calls in another MD to look at. The MD called in admits the patient to the hospital. My question is: Doesn't Medicare bundle the clinic visit into the admission even though patient was seen by a different MD?:)
Milwaukee WI
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Answers to your questions

1) Make sure your cardiologists are properly credentialed for their specialty. If they carry dual-certification (e.g. Internal Medicine and Cardiology) that may be part of the problem.

2) Yes, the clinic visit will be "rolled" into the admit. However ... it's possible if the two MDs are of distinctly different specialties that MD # 1's clinic visit may be separately reportable (e.g. MD #1 is a dermatologist; MD # 2 is a cardiologist).

F Tessa Bartels, CPC, CEMC