We gave flu injection to a patient and subsequently two days later saw the patient for a new well visit. Insurance has denied stating does not meet criteria for a new patient. We often have patients come in for labs and flu shots prior to the initial visit. Where can I find information to fight this?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki New Patient
- Thread starter Tosh
- Start date
SharonCollachi
Guest
While it won't help with your current situation, I would suggest you stop doing that. Who is ordering these labs? Who has determined the patient is well enough for a flu shot (frankly, I go to my local Walgreens for that)? Shouldn't they have a new patient visit where the doctor determines what labs need to be done, based on that particular patient's history and current needs?
Per AAFP: 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.
Defining “professional services”: Varying interpretations of what constitutes a “professional service” have been a source of confusion for practices trying to determine which patients qualify as new. CPT 2001 clarified the matter by defining professional services as “those face-to-face services rendered by a physician and reported by a specific CPT code(s).” The key phrases are “face-to-face” and “reported by a specific CPT code(s).” Suppose you provided the interpretation of an ECG for an inpatient you did not actually meet in person. When you see the patient in your office (assuming this occurs within the next three years), you would report the E/M service you provide using a new patient code since there was no face-to-face encounter during the inpatient stay. Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code since you did not have a face-to-face encounter with the patient when calling in her prescription. If you are in solo practice, all you need to remember to differentiate new patients from established ones is whether you provided a face-to-face service within the last three years. The situation is different, however, for group practices.
Special considerations for Medicare patients
A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate.
Per AAFP: 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.
Defining “professional services”: Varying interpretations of what constitutes a “professional service” have been a source of confusion for practices trying to determine which patients qualify as new. CPT 2001 clarified the matter by defining professional services as “those face-to-face services rendered by a physician and reported by a specific CPT code(s).” The key phrases are “face-to-face” and “reported by a specific CPT code(s).” Suppose you provided the interpretation of an ECG for an inpatient you did not actually meet in person. When you see the patient in your office (assuming this occurs within the next three years), you would report the E/M service you provide using a new patient code since there was no face-to-face encounter during the inpatient stay. Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code since you did not have a face-to-face encounter with the patient when calling in her prescription. If you are in solo practice, all you need to remember to differentiate new patients from established ones is whether you provided a face-to-face service within the last three years. The situation is different, however, for group practices.
Special considerations for Medicare patients
A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate.
dorinda05
Networker
This was a very well written reply. However, if our cardiologist reads an ekg or stress test while the patient is inpatient, then said patient is a follow up with same cardiologist in office after discharge, we bill as established as payer rejects (BCBS specifically) kept happening due to the same tid, same provider has already submitted a claim for said patient.
SharonCollachi
Guest
Then I would appeal with a photocopy of the CPT book, as it clearly says "face-to-face" services.
Dear BCBS:
(Introductory stuff identifying patient and claim)
On XX/XX/XX, John Smith MD was called upon to read an EKG for your member, FIRSTNAME LASTNAME, who was inpatient at XXXXXX Hospital. Dr. Smith did not evaluate the member, did not perform any face-to-face professional services with the member, and in fact, did not even meet the member.
Subsequent to the EKG reading, the member was seen in the office on XX/XX/XX and became our patient. We billed 99205, (type out definition). You then denied that claim stating the patient was an established patient and not a new patient.
According to the American Medical Association's CPT 2020 Professional Edition, Page 4, a new patient is one who has not received any professional services.... (type it out), and "professional services" is defined as ... (type it out). You are required to abide by the CPT (Current Procedure Terminology), as the Health Insurance Portability and Accountability Act determined that these codes were the official codes to be used in all transactions. The American Medical Association owns the copyright of these codes, and the definitions are set therein. The definitions are not subject to change.
Clearly you have erred in denying our claim, as this patient was not a new patient until the in-office visit of XX/XX/XX. We have attached the denied claim. Please reprocess and pay our claim. You may also pay any interest owed by law (insert a reference to your state law if there is one for timely payment), as you had a clean claim in your possession on XX/XX/XX.
SharonCollachi
Guest
Oh, by the way, I didn't write the first reply, that was from the AAFP. The second response was all me.