Wiki New vs. Established Patient

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ivygirl18@hotmail.com

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Hi everyone,

I have a new provider that was practicing infectious disease before joining our family medicine practice. If a patient from their old practice comes to see her at the new practice, would they be considered new or established? Going off of the new vs. established guidelines, they would be new since she was a different specialty before, but I want to see what others think.
 
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Per AMA/CPT "A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."

If it is the same physician, this is an established patient, regardless of specialty. The specialty clause applies to OTHER QHP or another physician.
 
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i disagree- since this is a different practice under a new TID this would be a new pt. the payers track this per TID so they would probably see it as a new pt also.
 
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luvbuix said:
i disagree- since this is a different practice under a new TID this would be a new pt. the payers track this per TID so they would probably see it as a new pt also.
Click to expand...

Whether this is a new patient or not is not based on TID. It is right in the definition: "...not received any professional services from the physician.... within the past three years."
In this situation, the patient is seeing the same exact physician. It is established.

https://www.ngsmedicare.com/web/ngs...e=97133&rgion=93623&selectedArticleId=1510596
Q10. If a provider who is credentialed with Medicare is starting to see patients at a new practice, and the patients were previously known to the provider from a prior practice, are these patients now considered to be “new” or “established” to the provider?
Answer: If the provider has seen the patient within the prior three years, the patient is not new to the provider, who should be submitting claims for an established patient, regardless of which practice the patient is being seen in.

EXAMPLE 2: Dr. Smith leaves "Clinic A" and joins "Clinic B." The patient follows Dr. Smith to "Clinic B."
Date of ServiceService ProvidedCPT Code
07/15/23Established E/M99213
Although Dr. Smith is at a different clinic, the patient is still an established patient with him. Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years.
 
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luvbuix said:
i disagree- since this is a different practice under a new TID this would be a new pt. the payers track this per TID so they would probably see it as a new pt also.
Click to expand...
My view is the patient would not be new in the scenario in the question even if they changed to a different specialty group. The guideline is not stating established to the group, specialty or TIN, it is established to the person/provider. It says "professional services from the physician". Wouldn't matter how the payer processes or "sees" it under a different TIN or not. The provider would be taking credit for the work associated with a new patient twice when it was inapproprate. They have already established care and relationship with the patient and the codes are valued as such. There can be some outlier exceptions but they are very rare. I see the debate could be, if the provider truly changed their credentialing, and the taxonomy was specialty code 44, Physician/Infectious Disease 207RI0200X, for example. Now the provider switched to taxonomy specialty code 8, Physician/Family Practice 207Q00000X. While the specialty is different, it is still the same individual person/provider. The specialty/subspecialty only comes into play if it is another (different) physician, not the same person. The key is the word OR. "A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

According to CMS fee schedule search:
99204 work RVU 2.60
99214 work RVU 1.92

Other examples:
https://www.bcbsri.com/providers/update/correct-coding-established-vs-new-patient
Examples of an established patient - Practice location change
A cardiologist leaves one group practice and joins another cardiology group practice. Some of the patients transfer their care to the new practice. One of the patients who transferred was established to the cardiologist presents to the new practice and sees one of the cardiologists. The patient is considered established to all the physicians in the new practice who are of the same specialty and subspecialty. A change in tax id or physical location doesn’t change that the patient is established.

  • If a doctor changes practices and takes his patients with him, the provider may want to bill the patient as new based on the new tax ID. This is incorrect. The tax ID does not matter. The provider has already seen these patients and has established a history. He cannot bill a new patient code just because he’s billing in a different group.
Where the patient was seen doesn't matter. If a physician cares for a patient in the hospital and then provides follow-up service in the office, the patient is established to the physician, even if it is the first time the patient presents to the office. If a physician changes practices and the patient follows him or her to the new practice, that patient is also considered established, assuming the physician saw the patient in the past three years.
 
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but there is part of the definition that you left out- the part in bold that says EXACT same specialty AND SUBSPECIALTY. since this provider changed practices AND specialties i would call this a new pt. i worked for uhc for 14 years & they would consider this a new pt also. just my 2 cents!
 
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csperoni said:
Whether this is a new patient or not is not based on TID. It is right in the definition: "...not received any professional services from the physician.... within the past three years."
In this situation, the patient is seeing the same exact physician. It is established.

https://www.ngsmedicare.com/web/ngs...e=97133&rgion=93623&selectedArticleId=1510596
Q10. If a provider who is credentialed with Medicare is starting to see patients at a new practice, and the patients were previously known to the provider from a prior practice, are these patients now considered to be “new” or “established” to the provider?
Answer: If the provider has seen the patient within the prior three years, the patient is not new to the provider, who should be submitting claims for an established patient, regardless of which practice the patient is being seen in.

EXAMPLE 2: Dr. Smith leaves "Clinic A" and joins "Clinic B." The patient follows Dr. Smith to "Clinic B."
Date of ServiceService ProvidedCPT Code
07/15/23Established E/M99213
Although Dr. Smith is at a different clinic, the patient is still an established patient with him. Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years.
Click to expand...
The NPI will be different with a new specialty. I believe this example is for the same specialty at a new clinic not a new specialty.
 
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luvbuix said:
but there is part of the definition that you left out- the part in bold that says EXACT same specialty AND SUBSPECIALTY. since this provider changed practices AND specialties i would call this a new pt. i worked for uhc for 14 years & they would consider this a new pt also. just my 2 cents!
Click to expand...
I read the definition like this:
A new patient is one who has not received any professional services from:
1) the physician or other qualified health care professional
or
2) another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice,
within the past three years.

As soon as part 1 is met by the patient receiving professional services from the same physician within the past three years, it is not a new patient.
I think we can all agree that the change in practice or TID is not relevant to new patient. And the only part we are disputing is the change in specialty.
If we are going by specialty, that would mean in this exact scenario, if we are using specialty of the same physician to determine new patient, then even if Dr A stayed at OFFICE1 but changed from ID to Internal Medicine, it would also be new, which would not be true.

tloeb said:
The NPI will be different with a new specialty. I believe this example is for the same specialty at a new clinic not a new specialty.
Click to expand...
The NPI would not change for the provider, regardless of specialty. The specialty would be updated, but same NPI. An individual provider would only have one NPI. Groups and organizations can have multiple NPIs, but not individuals.


This AAPC article also states this would be established. https://www.aapc.com/blog/51560-navigate-the-new-vs-established-patient-decision-tree/
 
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Good explanation and laying it out by Christine. Reading it as two separate sentences helps.
I still stand by my view that the specialty/subspecialty is WHEN IT IS A DIFFERENT PERSON not the same provider/individual/human being, regardless of if they switch specialty/clinics or not. It is still the same doctor.
Key words and terms: or another provider. Plural provider(s).
Has the patient received any professional services, Evaluation and Management (E/M) service or other face-to-face service from the provider (STOP reading here if yes)/or another provider (same exact specialty and subspecialty) in the same group within the previous three years?
Are the Providers the same Specialty?

This is from 2017 but has good explanation:

If the provider changes practices and the group TIN is different, will it get paid as new? Maybe, probably. But, getting paid doesn't mean it was coded correctly. The patient is still established to the provider. I also agree, the individual NPI does not change. https://www.cms.gov/Outreach-and-Ed...ducts/Downloads/NPI-What-You-Need-To-Know.pdf
"Your NPI won’t change, even if your name, address, taxonomy, orother information changes."
"Protect your NPI. As an Individual you are eligible for only one NPI regardless of the number of different places you furnish health care or the number of different contracts you may have with health plans andother health care providers. Your NPI is yours for life and will never expire or be recycled and assigned to a different health care provider. Only in rare and unique circumstances, such as fraudulent use of your NPI by another, will you be able to contact the NPI Enumerator in order to obtain a new NPI to replace the one that was initially assigned to you."
 
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csperoni said:
I read the definition like this:
A new patient is one who has not received any professional services from:
1) the physician or other qualified health care professional
or
2) another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice,
within the past three years.

As soon as part 1 is met by the patient receiving professional services from the same physician within the past three years, it is not a new patient.
I think we can all agree that the change in practice or TID is not relevant to new patient. And the only part we are disputing is the change in specialty.
If we are going by specialty, that would mean in this exact scenario, if we are using specialty of the same physician to determine new patient, then even if Dr A stayed at OFFICE1 but changed from ID to Internal Medicine, it would also be new, which would not be true.


The NPI would not change for the provider, regardless of specialty. The specialty would be updated, but same NPI. An individual provider would only have one NPI. Groups and organizations can have multiple NPIs, but not individuals.


This AAPC article also states this would be established. https://www.aapc.com/blog/51560-navigate-the-new-vs-established-patient-decision-tree/
Click to expand...
Oh my goodness I was mixing up NPI and Taxonomy in my brain even though I know the difference! OOPS! Seems strange that Noridian would have a misleading tool as it obviously is too simplified with all of the above interpretations.
 
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