Wiki New Patient Annual with Office Visit

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tammybarker

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We have noticed recently claims being denied by Medicare/Medicaid for new patients who are seen for an annual exam and office visit (problem) on the same day. We have been using new patient E/M codes for both the annual and office visit since the patient is considered new to our office. The denial (COB16) is stating new patient qualifications not met. I had submitted a reconsideration for a Medicaid claim and received a letter back stating "per guidelines, only 1 new patient code should be reported on a single date of service." I tried looking on the CMS.gov website and was unable to find anything related to this. Is anyone else having this issue and which of the codes are you changing to established? Does anyone have an official article stating these rules?

Thank you!
 
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Think about it, it doesn't make sense. The patient becomes established to the provider for whatever the second "visit" was. As soon as they have seen them face to face for the 1st one they become established after that. The second one would be established even if it is on the same day.

30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215)(Rev. 12461; Issued:01-18-24; Effective:01-01-24 Implementation: 02-19-24)

A. Definition of New Patient for Selection of E/M Visit Code Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

Also see these:
30.6.1.1 - Initial Preventive Physical Examination (IPPE) and AnnualWellness Visit (AWV)(Rev. 12546; Issued: 03-14-24; Effective: 05-15-24; Implementation: 05-15-24)

30.6.2 - Billing for Medically Necessary Visit on Same Occasion asPreventive Medicine Service(Rev. 12546; Issued: 03-14-24; Effective: 05-15-24; Implementation: 05-15-24)


I don't know which MAC you might be under but most have info on their sites like this:

Info from other plans as examples:
 
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A patient is only considered “new” for their very first face-to-face visit. Once that encounter happens they’re considered established for anything else you do that same day. That’s why payers won’t allow 2 new-patient codes on a single date of service. In short once the initial service is complete any additional visits that day must be billed as established (including an E/M service that is focused on a specific medical problem or complaint rather than a routine or preventive visit.)

When billing Medicare, CMS requires that additional qualifying E/M services be billed separately from the preventive service. The CMS website states, “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, we [Medicare] may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier-25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury, or to improve the
 
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