Wiki New patient vs Established

[tshifflett3]

Can a provider bill a new patient as an established patient? I ask because some of the carriers don't cover new patient telemed visits, but if the provider or group agrees to charge as an established patient is that allowed?

 

[thomas7331]

If the documentation in the medical record indicates that the patient is new to the provider by the CPT definition, then it would be incorrect coding to bill it as established. If the provider is knowingly billing it incorrectly to obtain payment for a service that would otherwise not be covered, then that could be considered fraudulent.

 

[Pathos]

I agree with Thomas, if the documentation supports a New Patient CPT code, then such a code should be reported. Both the provider and the coder have an ethical responsibility to do so regardless of a payer's billing policy. What you are describing could be viewed as "Downcoding" or "Undercoding" and in CMS' eyes is just as bad as "Upcoding" or "Overcoding".

 

[SharonCollachi]

While the insurance companies do not normally cover telemed for new patients, have they put in writing that they will not cover it during the pandemic? Every insurance company that we deal with has been pretty much bending over backwards to get care for their patients - waiving copays, relaxing restrictions on non face-to-face visits, etc.