Wiki NEW vs ESTABLISHED MEDICARE PT'S

[KIMBER035]

I have a Dr. that is questioning how we bill a Pt. with Medicare, whom he has seen within the 3 year period, & has coded a different ICD 10 code. He thinks it should be a "New" visit, not an Established visit. I have given him all kinds of info. about the billing of the two, BUT none of the info. I have given him states that putting a different/new complaint (ICD 10 code), will not effect/or effect the rule. Anyone have any suggestions of where I can get that info. in black & white to show him?

 

[CodingKing]

You wont find anything more specific w/ inclusions and exclusions since CMS finds the wording is as clear as it can be. Any is the key word

Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215)
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)

A. Definition of New Patient for Selection of E/M Visit Code

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty)within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.