New or Established Patient - employed by hospital

[brenroy]

If a patient is seen in a physicians office in a clinic and is an established patient with that physician, what are the rules for that same patient being seen by a specialty physician such as a GYN or ENT in the same clinic. This is a facility where the physicians are employed by hospital and the services are billed under the same NPI number for all physicians.

 

[Naveen Rachagolla]

NEW VS. ESTABLISHED
Many categories of E/M Services are further subcategorized by determining if the patient is new or established.
Whether a patient is new or established is determined by the length of time it has been since that patient has seen that physician. IF the patient has a face to face encounter with the pysiciam in the las three years, the patient is considered established. If that patient has not seen that provider in the last three years, the patient is considered a new patient. However, there are some exceptions to this rule:

The patient sees a physician in the same group practice: If the patient sees a physician in the same group practice, you will need to determine if the two physicians are of the exact same specialty and subspecialty. If they are, and the patient as seen them in the last three years, the patient will be considered as established patient.

Example:
05/01/2011- Patient A sees Dr. Smith ( Orthopedic surgery: Hand Surgery).
05/01/2012- Patient A sees Dr. Jones (Orthopedic Surgery: Foot and Ankle Surgery) in the same group practice.
When the patient sees Dr. Jones, she would be considered a new patient because, although the provider in the same group practice he is from a different subspecialty.The specialty and subspecialty of the providers is determined during the credentialing process with the insurance carriers.

The patient sees a provider that is on-call for the patients normal physician. This can be seen often in OB/ Gyn practices. When two physicians have independent practices cover for each other, the service is coded as if the physician is seen.

Example:
The patient sees physician A who is covering for Physician B for follow-up appointment. The patient has never seen Physician A before, but saw physician B last week. Because Physician B is covering for Physician A, the patient is considered an established patient.