New Pt codes

[janice.moore]

Must a physician charge a new patient CPT just because the patient meets the new patient qualifications? I am not considering it an error when he charges an established pt LOS in this instance. Thoughts?

 

[Lynda Wetter]

I'm confused by the question, why would you charge an Established pt code, if the patient meets the requirements for a New patient???

 

[FTessaBartels]

Here's one scenario

I work for pediatric plastic surgeons. Patients born with a cleft lip/palatte are usually followed for YEARS, even decades.

However, it's entirely possible that a patient goes more than 3 years between visits because his/her condition is stable and no additional surgeries can be done until the facial skeletal structure has matured. The surgeon is relying on the patient's pediatrician and/or dentist to alert the plastic surgeon if there is a need to see the patient sooner.

I've told my surgeons that such patients are - in payer and CPT parlance - "new" patients because they haven't been seen in over 3 years. But the surgeons refuse to bill them as such. They feel they have a history with the patient (and in their very early years were seeing them frequently and performing multiple surgeries). They are more comfortable billing an established patient visit.

Don't know your scenario, but that's one that comes up in our office several times a year.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[MnTwins29]

Interesting discussuion. Tessa, I am curious - do you ever have any problems with this from the perspective of consistent undercoding? Since we are always told that a pattern of undercoding is just as fraudulent as overcoding, I wonder if any payers (at least government payers) would consider this fraud. I am sure the commercial carriers don't mind paying the smaller fees!