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New Patient vs. Established Patient (Medicare & Healthy Blue)

K

kcoble01

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Hampton, VA
Patient comes in for a "New Patient Consult" and sees the PA no MD sign off. I know this is billed as established but if there was MD sign off could this be considered "NEW" I have been told yes. Can any one lead me to a specific POLICY for PALMETTO GBA & HEALTHY BLUE?? I would be eternally grateful. Thank you in advance for the help.
 
It seems like you are possibly confusing new vs established with incident-to. New vs established has nothing to do with who signed off on the note.
A patient seeing the PA who has not received professional services from your group in the past 3 years would be NEW. It would be billed under the PA with a supervising physician to clarify the specialty.

From Palmetto GBA:
For purposes of billing office and outpatient evaluation and management (E/M) services, the Centers for Medicare & Medicaid Services (CMS) defines patient type depending upon previous encounters with the provider. As per CMS, “a new patient is one who has not received any professional services (e.g., E/M service or other face-to-face service [e.g., surgical procedure]) from the physician or physician group practice (same physician specialty) within the previous 3 years.” CMS defines an established patient (PDF) as “a person who receives professional services from the physician, NPP, or another physician of the same specialty who belongs to the same group practice within the previous 3 years.”

Some non-Palmetto, but still good references:

PS - I am ignoring the use of the word "consult" above and using simply new vs established logic particularly as this is Medicare.
 
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