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...
