Wiki New visit or etsablished?

[Olena1988]

I am working with out-of-network coverage only. Our practice has a new provider, that came form another practice.
She is seeing patients now, which have been seen buy her before, but under dif TAX ID.
Can we bill new visits in this case? For example, UHC covers, but BCBS does not.
I checked some forums about this topic, but there is no specific answer about it. Thank you!

 

[thomas7331]

If the same provider sees the same patient within three years, it is established, regardless if it is under the same tax ID or a different one.

Don't rely on whether or not the insurance companies are paying or not because that is not a good indicator of the accuracy of the code. The insurance company may allow a new patient code simply because they do not have a previous claim on file within the three years, but that does not mean that the new patient code is necessarily correct. Code choice has to be supported by what the medical records support.

 

[Olena1988]

If the same provider sees the same patient within three years, it is established, regardless if it is under the same tax ID or a different one.

Don't rely on whether or not the insurance companies are paying or not because that is not a good indicator of the accuracy of the code. The insurance company may allow a new patient code simply because they do not have a previous claim on file within the three years, but that does not mean that the new patient code is necessarily correct. Code choice has to be supported by what the medical records support.

thank you for your response.
Yes, I understand that it is the same provider, however it is different TAX ID, which means new group, new practice, new billing address.
CMS states a definition that NEW PATIENT IS
An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years

Can you help me with this, please?

 

[thomas7331]

thank you for your response.
Yes, I understand that it is the same provider, however it is different TAX ID, which means new group, new practice, new billing address.
CMS states a definition that NEW PATIENT IS
An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years

Can you help me with this, please?

This is always an area of confusion, but it's easiest if you break it up into the two components:

The patient is new only if:

• They did not receive a face-to-face service from the physician of NPP within the previous 3 years.

AND:

• They did not receive a face-to-face service from another physician of the same specialty who belongs to the same group practice within the previous 3 years.

In the case you describe, if the patient saw this provider within 3 years, then that fails this first test and they are not new.

The specialty and group test only applies when they see a different provider in the practice. So, for example, if they are seeing another provider in your practice, and they had seen the new provider at their previous practice, then that would be new patient because the two different providers never saw the same patient within the same group.

Hope that makes it clearer?

 

[Pathos]

I agree with Thomas. When a payer looks at a claim to determine New vs. Established, the Tax ID is not as important as the group practice of the provider. For example, if the patient goes and sees his PCP at Internal Medicine Doc , and is then referred out to Doctor Heart from Cardiology Docs (both different group practices), the patient could potentially be considered New Patient for both visits.

Here is a good article on New vs. Established from my local MAC:

Noridian New vs. Established

Hope this helps!

 

[Olena1988]

Very helpful! Thank you so much!