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New Patient Code


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I work for a physician who joined our practice recently. One of his patient whom he saw previously at his old practice was in for a new patient appointment. I am getting a denial from Medicare stating my physician has already billed for 99204 in the past 3 years. But this was at his old practice and the most recent visit was her initial visit at the new practice. Is there a way around this 3 year rule in this case since the patient is new to the practice? I am new to billing and this is the first time I have come across this.


Jackson, TN
Best answers
FAQ from Medicare website

What is the definition of "new patient" for billing evaluation and management (E/M) services?
Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three 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. Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.