Question NEW vs ESTABILSHED VISIT

bharathiT

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Patient came office visit today(06/21/19 10.00AM)for ortho specialty .The patient was already seen on the ortho specialty at 06/21/16 08.00AM.

This scenario consider as new patient visit or EST patient visit.
 

Pathos

True Blue
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Beaverton OR
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Your question is valid in the sense where the 3 year cut-off begins. My previous job had me ask our MAC directly about this specifically, but let me first share the definition of New vs. Established and then give you the answer I got from them:

"New Patient
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.

Established Patient
Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years."

"Q13. A patient normally sees one Nurse Practitioner (NP) within a provider's practice, however, within three (3) years, he/she sees another NP within the same family practice, who is collaborating with a physician of a different specialty (orthopedic). Is it appropriate for the second NP to report a new patient visit?
A13. The second NP will bill "established" as NPs are all under the same specialty 50; they are not separated like physician specialties. Medicare interprets the phrase "new patient" to mean a patient who has not received any professional services such as E/M visits 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. See CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7
This link will take you to an external website.
."

Based on their answer, I would say the 3 year threshold ends after 1095/ 3 years have passed. In your scenario, the patient is still considered "Established", but would have been considered "New" if the visit was on 6/22/2019 instead.

Noridian - New vs. Established
Noridian - Ask the Contractor - May 18, 2017

All things said, check with your payer's policy for that patient, as they might have a more specific rule when it comes down to the nitty gritty.

Hope that helps!
 
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