New patient to provider or not

Cheezum51

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A little different scenario in the new versus established patient definition:

A doctor purchases the practice of another doctor of the same specialty. The practice, under the new owner, is now under a new group NPI number for his professional corporation. The new practice owner never saw any patients in the practice prior to purchasing it. The previous practice owner now works for the new corporation as an employee one day per week.

When the new practice owner sees a patient who had been examined by the previous owner, prior to the practice purchase, less than 3 years ago, is that visit with the new doctor coded using a new patient CPT code?

My opinion is that it is a new patient to the new practice owner since the practice is now registered with a new group NPI number and the NPI for the individual provider had not been affiliated with that practice before. If the patient were to be seen again by the prior owner, I think that would necessitate using the established patient codes.

Any input or clarification would be appreciated.

Tom Cheezum, O.D., CPC
 
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It goes like this: same provider or different provider of the same specialty and subspecialty who belongs to the same group practice. In my opinion, I'd say it qualifies as new because it's not the "same group" as it was before, despite being in the same physical location. The providers are still there, but they work for another "company" now. I assume the Tax-ID is different also..?
 

CodingKing

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This reminds me of the furniture company down the street that is always having a going out of business sale and changing its name and TIN every year. This is one of these situations that is so sticky it could probably take a team of lawyers to figure out. To me if the new practice also took over the medical records of the previous practice and it has not relocated; it should be treated as if it was the same practice. The whole purpose of the new vs established is whether you need to start from scratch and do a full workup, or is there sufficient information from previous encounters for the provider to go off that they don't.
 

Cheezum51

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CodingKing, this is an optometric practice and I'm referring to patients being seen for their annual comprehensive eye exams which are typically billed with level 4 99 or 92 codes.

I definitely see your point though.

Tom Cheezum, OD, CPC
 
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I don't know if this will help or not, but our MAC has this information posted:

"Medicare views physicians within the same group with the same specialty as the same person. A group is comprised of members having the same tax identification number. If there are different tax identification numbers, the physicians are not part of the same group for Medicare billing."....

"Q. Doctor A is new to our group. If a former patient sees Doctor A under our group, is this patient new or established? If the former patient has a visit with Doctor B, in our group with the same specialty as Doctor A, is the patient new or established?

A. If Doctor A sees his/her former patient, the service is an established patient visit. Doctor A's NPI shows the provider has seen the patient within the previous three years. If the patient sees Doctor B under the new group with the same specialty without seeing the Doctor A first under the new group, then the patient is considered a new patient because the Tax ID is different."....

"Members who share the same Tax ID are part of the same group. The location of services does not make a difference"

I'm still mentally trying to connect the dots to apply this logic to your situation; so far I've gotten this; You have Doctors X, Y, and Z, which are now "new" to Doctor A's group (the new owner). If Doctors X or Y or Z see an existing patient first, then they'd be established. If Doctor A sees the patient before Doctor X, Y or Z, then it would be a new patient.... I think. It can't possibly be THIS difficult. :confused:
 

Cheezum51

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Danskangel, definitely not as cut and dry as you'd think. I believe the fact that the practice has changed ownership and now uses a new group NPI makes the patients new when seen by the new owner, with his own NPI being new to the practice as well, since he never worked in the office prior to purchasing the practice. If the former owner sees the patient and it's been less than 3 years since their last visit with him, then I believe that would still qualify as an established patient.

Tom Cheezum, O.D., CPC
 

CodingKing

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Danskangel, definitely not as cut and dry as you'd think. I believe the fact that the practice has changed ownership and now uses a new group NPI makes the patients new when seen by the new owner, with his own NPI being new to the practice as well, since he never worked in the office prior to purchasing the practice. If the former owner sees the patient and it's been less than 3 years since their last visit with him, then I believe that would still qualify as an established patient.

Tom Cheezum, O.D., CPC

It looks like TIN is what describes a group practice not the group NPI. You can have multiple Group NPIs per TIN but you can only have 1 TIN assigned to a group NPI. You can even have multiple NPI's for the same office location. All of the groups under a single TIN are considered the same practice regardless of location and NPI. I think we need to leave the group NPI out of it as its fairly meaningless due to number of NPIs allowed per TIN. Lets also ignore the 3 year rule for now since its irrelevant if the other conditions are not met.

If the patient has been seen under the TIN before, they are established to the practice. That means, if they see anyone with the same specialty and subspecialty they are also established.

If the patient has not been seen under that TIN but they have seen the same provider under another TIN, they are considered an established patient.
 
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Cheezum51

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So in this situation, we have a new TIN and new doc so the patients, when seen by the new doc, are new to him but established to prior practice owner, even though he's working under the new TIN.
 

CodingKing

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So in this situation, we have a new TIN and new doc so the patients, when seen by the new doc, are new to him but established to prior practice owner, even though he's working under the new TIN.

Correct, they would be new to the TIN (practice) and new to the doc.
 
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