New Pt Qualifications

[brios82]

We had a patient that was seen for a Flu shot only (no face to face with any provider, MA only) and then came back for their first visit with the provider on a different day.
Would you consider this a New or Est. Patient?

We sent it as a New patient and was denied, saying we don't meet the new pt qualifications...

Thanks!

 

[sybutler]

New Patient Qualifications

CMS.gov FAQ - https://questions.cms.gov/faq.php?id=5005&faqId=1969 definition of new patient

What is the definition of "new patient" for billing evaluation and management (E/M) services?
Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. The AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.
(FAQ1969)

I would suggest contacting the carrier involved and obtain written documentation as to how they define a new patient. Perhaps speak with a provider representative/consultant if available.

Sue Butler, CPC, CIMC, CAWC

 

[brios82]

Thank you!
I had the print out from CMS but I didn't think to ask them for their definition, Thanks!!