New pts & the 3 year rule


Bullard, TX
Best answers
My 9 surgeons are questioning why they have to follow Medicare's & CPT's guidelines for new patients (the 3 year rule for the same tax id number) even on non-medicare patients. They want me to show them proof that 2 different doctors that bill under the same tax id number can't both bill a new patient code. I understand the rules & have explained them time & time again. I just can't find the PROOF that they are looking for. HELP...... Please.......
On the very first page of the E&M guidlines in the CPT manual (under the blue heading "New and Established Patient) it states:

"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."

And it goes on to define what an established patient is. Is it that this is a multi-specialty practice and the patient is seeing two doctors of different specialties within the same practice within the three year period? If so, I believe that's something that has to be appealed if/when it's denied. It also must be a recognized specialty. For example, I work for an orthopedic practice, Hand is recognized specialty, for whatever reason, Spine is not. If a general orthopedist refers a patient to see a spine specialist, there's not necessarily any appeal rights there based on the specialty because again, Spine is not a recognized specialty. At least not by Medicare and I think most payors pretty much follow them. I hope this helps...

I would remind them that you are following AMA Guidelines - not necessarily Medicare's & this is why the rule applies to all patients. Just like the other coder cited - show them the e/m guidelines in your cpt book.

Good Luck to you!