New vs Established Patient

allib04

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Tillamook, OR
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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?
 

csperoni

True Blue
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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.
 

allib04

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Tillamook, OR
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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.
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?
 

AmandaBriggs

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Coeur d'Alene, Idaho
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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.
 

thomas7331

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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?
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.
 

allib04

New
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Tillamook, OR
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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.
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:

"When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. A “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service. These professionals are distinct from “clinical staff.” A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service. Other policies may also affect who may report specific services."

CPT Coding Guidelines, Introduction, Instructions for Use of the CPT Codebook
 

newfiegirl

Networker
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Rochester, New Hampshire
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I have a slightly different question regarding New vs Established: When a patient is scheduled for a New Patient Physical exam and problem is also addressed during the exam, should the problem focused be coded as established? Thanks,
 

csperoni

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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?
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.
 
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