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
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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 ( You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.