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wentzks

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We have a new physician in our group but she is seeing a patient from her old practice (same specialty,within 3 years). When the patient comes to our office, do we code as an established even though we are a different TIN?
 
If patient has had face to face visit with the same provider in the last 3 years they are established no matter where the patient is seen. Specialty, subspecialty and TIN are not part if the equation. Those only come into play if they are established to the practice and seeing a new provider (to the patient).
 
CodingKing said:
If patient has had face to face visit with the same provider in the last 3 years they are established no matter where the patient is seen. Specialty, subspecialty and TIN are not part if the equation. Those only come into play if they are established to the practice and seeing a new provider (to the patient).
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What if the patient is coming to see another doctor in our practice, totally new to him, but has seen this new doctor to our practice in the last 3 years? He can bill new patient then, correct?
 
wentzks said:
What if the patient is coming to see another doctor in our practice, totally new to him, but has seen this new doctor to our practice in the last 3 years? He can bill new patient then, correct?
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Correct, under that scenario you can act as if the new doctor doesn't even exist. A lot of this depends on who the patient sees and in what order. As long as the patients first appointment with the practice is with someone they have not seen at another practice (in last 3 years) and you are good with charging new patient.
 
No, that is not true. If they saw your new provider within the last 3 years, they are considered established. Even if they saw a different provider, they are considered established. We have been dealing with denials because of this. We merged 2 companies together and need to bill established for everyone of the new doctors patients who were seen in the last 3 years.

Machelle Freeman, CPC
 
Machelle Freeman said:
No, that is not true. If they saw your new provider within the last 3 years, they are considered established. Even if they saw a different provider, they are considered established. We have been dealing with denials because of this. We merged 2 companies together and need to bill established for everyone of the new doctors patients who were seen in the last 3 years.

Machelle Freeman, CPC
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I have not been able to find this exact scenario covered in writing by Medicare, but a Novitas rep addressed a question about this at a session I went to last year, and her answer matches the guidance Machelle is giving here.
 
i'd be interested in the source. Let's say patient is established with Dr A.

Dr A is to join clinic B tomorrow

If the patients is seen by Dr B at Clinic B for the first time today they are new patient.
If the patient is seen at Clinic B at clinic B for the first time they are established patient because Dr A now works at Clinic B.
 
In the 2016 Coding Handbook, page 292, describes New and Established Patients. "In the CPT code coding system, a new patient is defined as 'one who has not received any professional services from the physician, or other physician of the same specialty who belongs to the same group practice, within the past three years.'"

If a patient saw physician A at Clinic A within the last 3 years, he is considered established with physician A. Once physician A joins a Clinic B, all his patients are now considered established to the new clinic, because physician A now belong to the same group practice as physician B.

From what I understand, when the physician comes into a new practice, their patients can follow them to the new clinic and see whomever they wish.
 
I interpret as same specialty and subspecialty only applies when the patient is established with the practice (based off TIN). Patient has not been seen by anyone in the practice so they are new to the practice thus same specialty and subspecialty does not apply. I've always understood the reason established visit only needs 2 of 3 components due patient information is accessible in the groups medical record or by personal knowledge of the physicians based on their previous encounters with the patient. You have neither if the physician is not in the office on that date and there is no medical record to access
 
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CodingKing said:
I interpret as same specialty and subspecialty only applies when the patient is established with the practice (based off TIN). Patient has not been seen by anyone in the practice so they are new to the practice thus same specialty and subspecialty does not apply. I've always understood the reason established visit only needs 2 of 3 components due patient information is accessible in the groups medical record or by personal knowledge of the physicians based on their previous encounters with the patient. You have neither if the physician is not in the office on that date and there is no medical record to access
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Personally, I totally agree with your POV here, and the reasoning for this situation being a "new patient" visit. Would be great if we could get guidance from Medicare in writing to clarify, instead of just "I heard a rep say it in a meeting".
 
I've always undertood the scenario as...

Assume patient is established to Dr. A at a previous location.

If Patient sees Dr. A at a new group, patient is established to Dr. A. And Dr. A seeing the patient then establishes patient to the new group.

However, if patient see Dr. B at the new group (where Dr. A now works) but hasn't been seen at that group before, the patient is is new to Dr. B, but that visit with Dr. B would also establish to the group moving forward. A new set of records is established.


However, interesting read here with some citations..

http://thehappyhospitalist.blogspot.com/2014/02/New-vs-Established-Patient-Definitions-CMS-CPT-Resource.html

CHANGE IN GROUP PRACTICE SCENARIO

How should a physician or NPP code patients after they have left one group practice and joined another? Under a new group or solo practice, the physician would have a new tax identification number. However, the definition of a new patient says they cannot have received professional services in the last three years from the physician or qualified health care professional. Some payer algorithms may not be able to identify the new vs. established patient decision for physicians or NPP who change tax identifications. Some may. To bill and code correctly the correct interpretation of this scenario says to bill established patient care codes if the physician or NPP has seen the patient for professional services in the last three years.

What if a physician changes groups and one of their established patients is seen in the new group for the first time by a physician or non-physician practitioner in the new group who has never seen the patient and has no records on the patient? Since the patient is established to the physician new to the group, the patient is established to all physicians and qualified health care professionals in the group. Established care codes should be used.

But this is not an official resource!


Once upon a time, I knew of a citation that explained this from one of the carriers. Will keep digging.
 
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Here is another interesting way to look at it.


Patient sees Dr. A at old office within the past 3 years.

Dr. A leaves and joins a new group.

Patient schedules visit at the new group and has never been see before at the new group. Group has no record, no chart, no anything for patient.. Scheduling department schedules patient with Dr. B.

The billing department has ZERO idea that this patient was seen before by Dr. A when he/she worked at the old office. Again, they have no records, and no bills. Dr. B has no clue that the patient was seen by Dr. A before at his partner's old practice.

The usual course of action is to ask if the patient has ever been seen here before when scheduling? They will respond, No. Personally, when scheduling, I have NEVER had asked of me, if I have ever been seen (insert list of doctors) at another office before???

Nor do I think it's feasibile to ask Dr. A.. "He we have Judy Smith coming in as a new patient tomorrow. She's beeing seen by Dr. B. You by chance didn't see her within the past 3 years, did you?"


I would think that the new vs. established is linked to the NPI and TaxID number when it becomes established.

There is no link for the new provider NPI number and TaxID to that patient for a carrier (or the office staff) to know that this patient was previously seen and might be established.

The staff would bill it as new, and if the cross-linked record exists, it will bump out on the EOB as a denial.
 
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