New Pt vs Est Pt

Messages
2
Best answers
0
We are an FQHC (Federally Qualified Health Center) Health Department with the following departments: Behavioral Health, Medical, Reproductive Health, and OB. Providers from the privately owned OB clinic here in town come to our facility and see OB patients 2 days a week.
My question is this: if a patient sees Dr. AZ at that doctor's clinic, and then decides to come to our facility because the care is cheaper, is the patient's initial visit in our facility a new patient visit, even though they've seen Dr. AZ for care?
The Tax ID & facility NPI numbers are going to be different on the claim. The only similarity is the provider's NPI number.

So, here would be the scenario:
Patient 12345 seeing Dr. AZ for OB care who has his own provider NPI number
Dr. AZ's clinic has their own Tax ID & facility NPI numbers
Our facility OB clinic has our own Tax ID & facility NPI numbers
Patient sees Dr. AZ initially at his clinic in September
Now patient sees Dr. AZ in our facility OB clinic in October
Is Patient 12345's visit with us in October a new patient visit, or an established patient?

The CPT book states: "a new pt is one who has not rec'd any professional svcs from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. And that "an established pt is one who has rec'd professional svcs from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."

To me, according to the CPT book description above, I'd say that the patient's visit with Dr. AZ in our facility would be considered a new patient. However, another person in our facility that I've posed this question to states that just because the patient is new to our clinic does not mean that they're new to the provider. My argument to that is that the provider is the same, but the group practice is different.
Another example would be a new provider starting & seeing patients at our facility bringing his established patients from a previous practice he belonged to. She is stating that those patients would not be billed as new patients in our facility. I say they're new patients, and my argument to that is because they are new patients to our facility, which is different than the practice the provider previously belonged to.

Thank you very much for any guidance anyone can provide!!

Marty L., CPC
10/21/2016
 

Chelle-Lynn

True Blue
Messages
729
Location
Modesto, CA
Best answers
0
We are also an FQHC facility with multiple locations and services and we have run into similar issues. We have advised our staff to use the following decision tree when determining if it is a new or established patient.

Decision tree:
o Is the billing under the same tax ID number?
o Is the doctor the same doctor type previously seen? Such as family practitioner vs. ob/gyn vs. specialists, etc.
o Has three years passed since this patient was last seen?

If the answer is yes to all three questions, then it is an established patient. If you answer no to any of the questions, then it can be reviewed for a new patient visit.
 

CodingKing

True Blue
Messages
3,955
Best answers
1
If its the exact same physician its automatically established regardless of where they are seen. The rest only comes into play when it's a different person seeing the patient.
 

newfiegirl

Networker
Messages
72
Location
Rochester, New Hampshire
Best answers
0
I have a similar situation that I am looking for some clarity with. I also work in an FQHC facility. We have providers who provide both OB and PC to the same patients. My question is if a patient sees their doc as a PC and then see the same doc for a new prenatal is that patient considered new or established for prenatal care? Also, if an established prenatal patient sees a new PC doc to establish care within the same facility is that pt considered new to the PC. All of these services are provided under the same tax ID number. Thanks for any help with this.
 

CodingKing

True Blue
Messages
3,955
Best answers
1
I have a similar situation that I am looking for some clarity with. I also work in an FQHC facility. We have providers who provide both OB and PC to the same patients. My question is if a patient sees their doc as a PC and then see the same doc for a new prenatal is that patient considered new or established for prenatal care? Also, if an established prenatal patient sees a new PC doc to establish care within the same facility is that pt considered new to the PC. All of these services are provided under the same tax ID number. Thanks for any help with this.

Reason for being seen is not taken into consideration


If its same provider they have seen before (doesn't matter if at the FQHC or another practice) regardless of specialty its always established.

If its a different provider and has the same specialty and subspecialty its established. Condition being treated is not considered, its the specialties of the provider that is considered.
 
Top