• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Established visit vs. Establishing Care visit

Create Wiki Sort by votes
K

kelly.kirkman@icloud.com

New
Messages
7
Location
Hallettsville, TX
Best answers
0
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?
 
0
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
 
0
Missdeehamp said:
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
Click to expand...
Thank you so much for your response. I am still relatively new to the billing world and currently enrolled in the certification course through AAPC. Would you mind telling me where in our contract I might find this information? I want to make sure I know where to look when I get with our contracting employee to find this information. Like I said, still kind of new to all of this and was thrown into this position with not much training. I appreciate your time and help with my question. This is super helpful!
 
0
While the above is good advice; if you are a RHC, are you billing encounter based on a UB and reimbursed all-inclusive (like T1015)? Some plans want the regular CPT coded but you have to report a revenue code with it. Others want both the CPT for reporting purposes along with a HCPCS and rev code. You have to learn what the health plan being billed wants. RHC & FQHC billing and coding is different. You would also have to check the contract. If you are a hospital/clinic FQHC or RHC this process should already be known and in place. Did something change recently or do you have a new employee who is billing incorrectly? Did something change recently? Otherwise, this would have been a problem historically. Has anyone checked to see what date range or what claim this has happened with? Is it only one health plan or all? Did anyone check the specific health plan newsletters and provider portal for updates? Examples (this is for telehealth but just an example): https://www.bcbstx.com/provider/med...0fqhc-rhc-adding-home-telemonitoring-services

(Indiana but as an FYI/example) https://providernews.anthem.com/ind...ims-submissions-for-fqhcsrhcs-for-t1015-24218
 
0
amyjph said:
While the above is good advice; if you are a RHC, are you billing encounter based on a UB and reimbursed all-inclusive (like T1015)? Some plans want the regular CPT coded but you have to report a revenue code with it. Others want both the CPT for reporting purposes along with a HCPCS and rev code. You have to learn what the health plan being billed wants. RHC & FQHC billing and coding is different. You would also have to check the contract. If you are a hospital/clinic FQHC or RHC this process should already be known and in place. Did something change recently or do you have a new employee who is billing incorrectly? Did something change recently? Otherwise, this would have been a problem historically. Has anyone checked to see what date range or what claim this has happened with? Is it only one health plan or all? Did anyone check the specific health plan newsletters and provider portal for updates? Examples (this is for telehealth but just an example): https://www.bcbstx.com/provider/med...0fqhc-rhc-adding-home-telemonitoring-services

(Indiana but as an FYI/example) https://providernews.anthem.com/ind...ims-submissions-for-fqhcsrhcs-for-t1015-24218
Click to expand...
Hi Amy,

Thank you so much for your response. I am waiting to hear back from our CFO regarding our contract details. I have been with this facility for just over a year and since I have been here this has been an issue. Previously I was instructed to just have the code changed to established, but after starting my billing certification course and learning a bit more about the ins and outs I feel like this issue could be avoidable. We do report with the T code like you stated but that part does not go out on the claim. For what reason, I do not know. I am somewhat flying blindly on a lot of things with training because of some other issues that were going on when I started here. Luckily I have previously taken a coding course and that has helped. I appreciate you taking the time to respond and help me with this situation.
 
0
When you say "establishment of care visit and it has to be coded as a regular visit." what do you mean exactly? If a provider saw a patient in the ED and then sees that patient in the clinic, they are established to the provider. It is not where they were seen, it is that the provider saw the patient in any setting. What does this statement mean to you? "establishment of care visit and it has to be coded as a regular visit." Are you talking about 9920_ versus 9921_ or something else?

It's because if it is a commercial plan, they may not want the T codes and you would have to revert to using the "regular" CPT codes. The T may be captured on the claim due to the way your billing system is set up. It might track it internally but either converts it to an E/M, etc. or someone is manually changing it when the claim goes out the door.
If you are a staff coder at the individual contributor level, this sounds like something bigger than a staff coder should be figuring out or handling. Sounds like the facility doesn't know how to bill correctly according to each plan and/or the contract information. Either that or, there could be something wrong with the way the billing system is set up internally causing issues with POS and billing in facility vs. outpatient/office. You need to look at the rejection and/or denial reasons on the claims. This is more a data analytics and higher level issue sounds like to me. I don't think you're going to fix this at the end user staff level. There needs to be someone figuring out which health plans, commercial vs. government payer etc., how many claims, which service types or codes are impacted, and when it started. A technical person should be looking at the billing system and the internal setup. This should be configured to automatically convert coding onto the claims correctly. Like, the commercial BCBS needs to be converted from a facility claim (UB) to a profee claim (1500 837) and the billing/rendering/pay-to NPIs and EINs need to be corrected listed if you are billing an office/clinic/outpatient even if the "group" is the hospital. Like the EIN might be the hospital/corporate but the rendering and clinic NPI would be listed on the claim for POS 11 for example. On top of that, if services like X-Rays, Labs, EKG, etc. you may be running into TC/PC issues if those are performed at the facility and split billing is happening.

 
0
amyjph said:
When you say "establishment of care visit and it has to be coded as a regular visit." what do you mean exactly? If a provider saw a patient in the ED and then sees that patient in the clinic, they are established to the provider. It is not where they were seen, it is that the provider saw the patient in any setting. What does this statement mean to you? "establishment of care visit and it has to be coded as a regular visit." Are you talking about 9920_ versus 9921_ or something else?

It's because if it is a commercial plan, they may not want the T codes and you would have to revert to using the "regular" CPT codes. The T may be captured on the claim due to the way your billing system is set up. It might track it internally but either converts it to an E/M, etc. or someone is manually changing it when the claim goes out the door.
If you are a staff coder at the individual contributor level, this sounds like something bigger than a staff coder should be figuring out or handling. Sounds like the facility doesn't know how to bill correctly according to each plan and/or the contract information. Either that or, there could be something wrong with the way the billing system is set up internally causing issues with POS and billing in facility vs. outpatient/office. You need to look at the rejection and/or denial reasons on the claims. This is more a data analytics and higher level issue sounds like to me. I don't think you're going to fix this at the end user staff level. There needs to be someone figuring out which health plans, commercial vs. government payer etc., how many claims, which service types or codes are impacted, and when it started. A technical person should be looking at the billing system and the internal setup. This should be configured to automatically convert coding onto the claims correctly. Like, the commercial BCBS needs to be converted from a facility claim (UB) to a profee claim (1500 837) and the billing/rendering/pay-to NPIs and EINs need to be corrected listed if you are billing an office/clinic/outpatient even if the "group" is the hospital. Like the EIN might be the hospital/corporate but the rendering and clinic NPI would be listed on the claim for POS 11 for example. On top of that, if services like X-Rays, Labs, EKG, etc. you may be running into TC/PC issues if those are performed at the facility and split billing is happening.

Click to expand...
I apologize for my confusion. We bill clinic claims on a 1500 claim form. Medicaid claims are totally separate, and I think that is where I got confused.

What I mean as far as established after an ER visit is, the patient will see the ER doctor, different NPI, different taxonomy. Then, the patient may come into our clinic and see a clinic doctor, different NPI and taxonomy, for a follow up to their ER visit or even to establish care with our Clinic. There are are also specialty doctors that visit our clinic from time to time that our clinic doctor's will refer their patients to, we are getting denials on those new patient/establishing care visits as well, when technically the doctor IS establishing the care of this patient for the first time. From what I understand and learned in my coding course, these types of visits would/should be coded at the new patient level. We are reviewing our contract to see what it says about this situation. What would be ideal is that I don't have to submit a reconsideration for all of these claims and they would just process correctly. The price difference between these types of visits is not big enough to warrant that much extra work, in my opinion, but I would be happy to do whatever it takes to make sure we are paid accordingly.
 
0
kelly.kirkman@icloud.com said:
I apologize for my confusion. We bill clinic claims on a 1500 claim form. Medicaid claims are totally separate, and I think that is where I got confused.

What I mean as far as established after an ER visit is, the patient will see the ER doctor, different NPI, different taxonomy. Then, the patient may come into our clinic and see a clinic doctor, different NPI and taxonomy, for a follow up to their ER visit or even to establish care with our Clinic. There are are also specialty doctors that visit our clinic from time to time that our clinic doctor's will refer their patients to, we are getting denials on those new patient/establishing care visits as well, when technically the doctor IS establishing the care of this patient for the first time. From what I understand and learned in my coding course, these types of visits would/should be coded at the new patient level. We are reviewing our contract to see what it says about this situation. What would be ideal is that I don't have to submit a reconsideration for all of these claims and they would just process correctly. The price difference between these types of visits is not big enough to warrant that much extra work, in my opinion, but I would be happy to do whatever it takes to make sure we are paid accordingly.
Click to expand...
If it is all being billed under the umbrella of the facility Tax ID it may not matter the NPI or taxonomy. Further, there may be a component of NPP (a.k.a. midlevel) issues such as NP, or PA if they are also seeing patients. Not all health plans recognize or follow the exact same subspeciality or taxonomy codes that CMS does. And, if RHC, may not always be 1:1 with CPT/AMA new vs. established E/M. Some plans/contracts may only look at the Tax ID. Therefore, if all under the same Tax ID, regardless of specialty/subspecialty, once a provider sees them they are then established to all. Doesn't matter if that next provider has not seen them before. Doesn't matter if you internally call it an "establishing care visit". They are new one time only, the rest is established to all. Look at what your reason codes are on the ERA/EOB. It will tell you. I am guessing the manual or contract specifically has a Tax ID section.

You are correct in what you learned in your coding course. However, real-world scenarios and courses; what is good for one health plan vs. government vs. RHC vs. outpatient, etc. is not always the same for all. Real world is totally different than book/course coding.
 
You must log in or register to reply here.
Top