Wiki New Patient Criteria

[waymanl]

I am looking for clarification to the question of when to code a new patient. If the practice is a multi specialty practice, same tax ID # throughout the group, and the patient sees a specialist first and then sees a PCP after, can the PCP bill for a new patient, even though the specialsit was seen first(and billed a new patient)?


Lisa M Wayman

 

[MarcusM]

http://www.aafp.org/fpm/2003/0900/p33.html

By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years.

In a multi-specialty practice, a patient might be considered new even if he or she has received care from several other physicians in the group and a medical record is available. The distinguishing factor here is the specialty designation of the provider. For example, take a patient who has been seen regularly by the pediatrician in your group. The patient is now 18 years old and wants to transfer care to a family physician in the same group. When she sees the family physician, she’ll qualify as a new patient because the family physician is in a different specialty than her previous physician. This is the case even though the family physician might be treating her for an existing problem and referring to her established medical record.

Medicare has a list of specialty and sub-specialty designations it recognizes for payment purposes. Other payers may use this same list or may recognize more areas of expertise based on credentialing information.

 

[waymanl]

Thank You