Wiki New Patient vs Establish Patient

[mckaya]

Texas Medicaid Provider Handbook
A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider.

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility.

Question, Is it an audit finding if the provider rendered services within the three year period while affiliated with a different group?
January 5th, 2017 provider rendered services at ABC Clinic of Dallas
April 25th, 2019 provider rendered services at EZ Clinic of Dallas
Same provider, same member different clinic

CMS does not address the provider at different locations, if they do please provide me the link
Thank you

 

[mckaya]

I found my answers on a contractor for CMS-Nordian Healthcare Solution website
If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and sub-specialty at a location where the first physician also practices, this is also an established patient situation.

 

[trarut]

While it didn't used to be this way, my experience over the last 5-7 years has been that the visit history now follows the provider. We have had several providers join our private practice from other hospital systems in town and some of their patients followed them. We were not able to bill new patient visits because they had a history with the provider and yes, we did try appealing based on how the guidelines are written. I think it's easier to track now that we're using NPIs and those numbers follow the providers from practice to practice.

 

[CodingKing]

Group Practice is not taken into account when its the same provider. It doesn't matter if they saw the patient in NY and then in Los Angeles.
Its been that way for years, however NPI made it easier to track down incorrect application of the new patient rules.