allib04
New
Our clinic had a patient come in to establish care. They had been to our clinic before but only to get a vaccine and only saw a nurse. Would this patient be new or established?
So, what I'm getting from your response is that the patient must have seen a physician of some sort in the practice, not a nurse, to be considered established, correct?Established. From CMS guidelines:
New Patient: 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.
Established Patient: An individual who receives professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years.
The nurse must work under the supervision of a physician who ordered the vaccine, therefore received professional services.
Technically, a face-to-face service with the physician or NPP is required in order for the patient to be established, so if they only saw the nurse, that would not make them established. However, different payers use different rules for making the determination as to what services will establish a patient with a particular practice. In this situation, I would bill the patient as new, but if the payer denies it for that reason, you'll need to either appeal or change the code to established and send a corrected claim.So, what I'm getting from your response is that the patient must have seen a physician of some sort in the practice, not a nurse, to be considered established, correct?
Even if they only received a vaccine? And the clinical staff that performed the service is a nurse (not an advance practice nurse)? I also read under the CMS guidelines after I responded to the previous response:I'm interpreting this to mean because your patient had received a professional service under the supervision of a physician (even if they only saw a nurse) the patient would be considered established.
My interpretation is that since your nurse must work under the supervision of a physician/NPP who ordered the vaccine, this would be established. As @thomas7331 suggested, you could try billing new and changing when denied. Note my use of "when" not "if" denied, because I don't think any carrier will pay as new.So, what I'm getting from your response is that the patient must have seen a physician of some sort in the practice, not a nurse, to be considered established, correct?