Wiki New vs Established Visit after Hospitalization

[MaryG215]

Our M.D.'s cover rounds at the hospital and the hospital does all of the billing (our MDs get a stipend for covering). Often when patients are discharged, they are referred to our clinic to establish care with a provider. If the patient is seeing a different provider than they saw in the hospital, can we bill a new patient/consult for this first visit in our clinic?

 

[CBLENNIE]

Is your provider that saw the patient in the hospital and your provider that they see in the clinic to establish care with of the same specialty & sub-specialty? If so, then it is not a new patient because the provider who saw the patient in the hospital has seen the patient within the last 3 years per CPT guidelines. The guidelines state that any professional service was received, an inpatient visit is a professional service. Here is the CPT E&M decision tree for New vs. Established patient.

 

[SSingler]

I have a situation where our NP did a new visit for in patient palliative care while pt was in the hospital in Oct. Pt was admitted again Nov and our NP saw the pt at that time. NP billed for a new visit. Our third party billing vendor is stating the Nov visit should be billed as an established visit not new. Also, the billing vendor is stating that if patient was seen by our NP as an outpatient palliative and is admitted to the hospital a month later, that hospital visit should be billed as an established visit. I thought the new visits depended on each hospital stay. Any help would be greatly appreciated.

 

[Cmama12]

I have a situation where our NP did a new visit for in patient palliative care while pt was in the hospital in Oct. Pt was admitted again Nov and our NP saw the pt at that time. NP billed for a new visit. Our third party billing vendor is stating the Nov visit should be billed as an established visit not new. Also, the billing vendor is stating that if patient was seen by our NP as an outpatient palliative and is admitted to the hospital a month later, that hospital visit should be billed as an established visit. I thought the new visits depended on each hospital stay. Any help would be greatly appreciated.

No, see the decision tree in the post above. In your scenario, the October visit would be new patient and anything after that would be established. The hospital codes don't distinguish though between new and established. So it would only be if you were billing an office E+M

 

[SSingler]

No, see the decision tree in the post above. In your scenario, the October visit would be new patient and anything after that would be established. The hospital codes don't distinguish though between new and established. So it would only be if you were billing an office E+M

Thank you for your response. I was thinking the same thing. The 3rd party billing was causing me to doubt myself.

 

[SSingler]

I have another question. Patient was seen in the hospital as initial visit for palliative care. After discharge pt is seen as outpatient palliative care by the same group at home, would the home visit be billed as new or established? This has been a discussion in the office. I think it should be established. Any help would be greatly appreciated.

 

[Cynthia Hughes]

I have another question. Patient was seen in the hospital as initial visit for palliative care. After discharge pt is seen as outpatient palliative care by the same group at home, would the home visit be billed as new or established?

The patient is established. The same rules for new vs. established apply because they are included in the guidelines for the E/M section and not just certain new and established patient codes. Cindy

 

[SSingler]

The patient is established. The same rules for new vs. established apply because they are included in the guidelines for the E/M section and not just certain new and established patient codes. Cindy

Thank you for your quick response. Just a follow up question. At the initial in-patient palliative visit, the consent to treat and be signed on to service is completed. This is completed at the initial out-patient visit as a "new" patient visit. Would the visit after being discharged from the hospital still be an established visit? I think it would.

 

[csperoni]

Thank you for your quick response. Just a follow up question. At the initial in-patient palliative visit, the consent to treat and be signed on to service is completed. This is completed at the initial out-patient visit as a "new" patient visit. Would the visit after being discharged from the hospital still be an established visit? I think it would.

The patient is established per coding guidelines, regardless of how the appointment is scheduled, the forms filled out, or the type of work being performed.
There are many situations where a patient could have an appointment type/scheduled as new, but is not new from a coding perspective. Example:
Patient referred to gynonc for ovarian cyst. Gynonc sees patient first time 01/01/2021 - orders some test, has additional appts. On 06/01/2021 the gynonc says "We're not concerned about this. No change in size. Simple cyst. Get regular gyn care and come back if needed." 2 3/4 years later patient has abnormal PAP and general obgyn refers back to gynonc, schedules for 05/01/2024. The office will often schedule that 05/01/2024 as a new patient for a variety of ADMINISTRATIVE or CLINICAL reasons. The interim history needs to be done. New patient paperwork will be completed. Records relating to this new problem need to be obtained. The length of the appointment may be longer to accomodate these.
Regardless, when it's coded, it is an ESTABLISHED patient. Doesn't matter that it's a new problem. Doesn't matter that the clinician took a thorough history. Doesn't matter that additional forms or paperwork were completed. Doesn't matter that additional records are obtained and reviewed. All these items could potentially contribute to a different level, but it doesn't make the patient new when they were treated by the clinician (or another clinician in the group of the same specialty) in the past 3 years.
The decision tree posted a few days ago by @CBLENNIE tells you exactly how to code the services.

 

[SSingler]

The patient is established per coding guidelines, regardless of how the appointment is scheduled, the forms filled out, or the type of work being performed.
There are many situations where a patient could have an appointment type/scheduled as new, but is not new from a coding perspective. Example:
Patient referred to gynonc for ovarian cyst. Gynonc sees patient first time 01/01/2021 - orders some test, has additional appts. On 06/01/2021 the gynonc says "We're not concerned about this. No change in size. Simple cyst. Get regular gyn care and come back if needed." 2 3/4 years later patient has abnormal PAP and general obgyn refers back to gynonc, schedules for 05/01/2024. The office will often schedule that 05/01/2024 as a new patient for a variety of ADMINISTRATIVE or CLINICAL reasons. The interim history needs to be done. New patient paperwork will be completed. Records relating to this new problem need to be obtained. The length of the appointment may be longer to accomodate these.
Regardless, when it's coded, it is an ESTABLISHED patient. Doesn't matter that it's a new problem. Doesn't matter that the clinician took a thorough history. Doesn't matter that additional forms or paperwork were completed. Doesn't matter that additional records are obtained and reviewed. All these items could potentially contribute to a different level, but it doesn't make the patient new when they were treated by the clinician (or another clinician in the group of the same specialty) in the past 3 years.
The decision tree posted a few days ago by @CBLENNIE tells you exactly how to code the services.

Thank you for the explanation. This is a new line of business for the company and we have had many discussions about it.

 

[Deb LaVancher]

No, see the decision tree in the post above. In your scenario, the October visit would be new patient and anything after that would be established. The hospital codes don't distinguish though between new and established. So it would only be if you were billing an office E+M

This has been a discussion in our Palliative Billing office. The New vs Established and Initial vs Subsequent visits. So Initial visit does not mean new patient, right? Many of our patients are admitted to the hospital several times a year. Prior to a hospital admission we could have been seeing them at home or at a Nursing Home. So we can bill an "initial" visit(for the first visit of that admission) every time the patient is admitted to the hospital even though they are not a new patient to us?

 

[jkyles]

So we can bill an "initial" visit(for the first visit of that admission) every time the patient is admitted to the hospital even though they are not a new patient to us?

Hi there, yes. The initial/subsequent visit concept applies to the specific observation/admission period.

 

[Deb LaVancher]

Thank you very much.