Wiki Established Vs New

[karbaker]

Patient is established with our group but went to the ER and our Dr was asked to Consult, pt status was Outpatient and we billed 99204, now B/C
has denied, Not new patient. Doesnt the fact that seen in hopital setting allow us to bill 99204, keep in mind B/C does not accept Consult codes. We are a Cardiology group.

Thanks
Karen

 

[Nancy Peavler]

Not established if seen in 3 years by practice

NO. CMS rules are followed by most carriers and they state any service by any one on your group within the last 3 years means the next service filed makes the patient established.

 

[Colliemom]

Was this a Medicare plan? Because our local BCBS does cover consultation codes. If it is a Medicare plan, you can use 99284. If it is a commercial plan, you should be able to use 99244.

 

[mitchellde]

Patient is established with our group but went to the ER and our Dr was asked to Consult, pt status was Outpatient and we billed 99204, now B/C
has denied, Not new patient. Doesnt the fact that seen in hopital setting allow us to bill 99204, keep in mind B/C does not accept Consult codes. We are a Cardiology group.

Thanks
Karen

If the provider is called to the ER to see a patient you use the ER levels not the established patient levels with the ER POS not outpatient. This is in the MCM.