Wiki Established visit vs. Establishing Care visit

[kelly.kirkman@icloud.com]

I work for a small Rural Health Clinic. Our hospital and clinic fall under the same tax ID but have different NPI numbers. Commercial payers, mostly BCBS, have been sending quite a few level of care denials related to clinic office visits. For instance, a patient comes into our clinic for follow up after a visit to the emergency room, and also to establish care. The correct coding for this situation would be an established visit. However, since the patient was already seen in our emergency room, insurance will reduce the level of service saying we can not bill for an establishment of care visit and it has to be coded as a regular visit. This also causes issues with our visiting physicians who see patients in our clinic who have been referred to them by doctors of our clinic.

Does anyone have any advice on this situation?

 

[Missdeehamp]

A few things I would look at before accepting the denial as valid:

1. Verify whether the payer is applying the CPT definition of a "new patient" correctly.
Per CPT, a patient is considered new if they have not received professional services from the physician or another physician of the same specialty/subspecialty within the same group practice during the previous 3 years.
An Emergency Department visit alone does not automatically make a patient established for a primary care provider. The ED physician is typically a different specialty than Family Medicine or Internal Medicine.

2. Determine whether the denial is being driven by the Tax ID, NPI, or payer-specific provider grouping logic.
Some commercial payers group providers under the same Tax ID and incorrectly treat all encounters within the organization as if they occurred within the same physician group. If this is happening, request the payer's written policy and compare it against CPT guidelines.

3. Review the provider specialties on file with the payer.
For your visiting specialists, if the specialist is a different specialty than the referring clinic provider, the patient may still qualify as a new patient under CPT guidelines even when seen within the same organization.

4. Appeal with supporting documentation.
When appropriate, include:
* CPT definition of a new patient
* Rendering provider specialty
* Prior provider specialty seen by the patient
* Dates of service demonstrating no professional services from the same specialty/subspecialty within the previous 3 years

5. Review your payer contracts.
I've seen situations where a payer contract contains language that differs from CPT methodology and groups all providers under a single entity. If so, the issue may be contractual rather than a coding error.
My first question would be: Are these denials occurring because the patient was seen by an ED physician, or because they were seen by any provider within the hospital/clinic system under the same Tax ID? That distinction will help identify whether this is a CPT interpretation issue or a payer configuration issue.
Dee Daniels
Founder | Elevare Management Solutions
Revenue Cycle Management Consultant
DDaniels@elevaremgmts.com
www.elevaremgmts.com