Question New vs. Established when physician joins another practice

tpkeith

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OB/Gyn physician is closing practice and joining another practice down the street. I understand patients seen prior to closing will be established when he or the other midlevels see patients at the new location. However, what if the patient sees another provider in the new office that was seen by the provider in the old office? The patient would be established with the joining provider, but new to the new office and that provider. I would assume the patient would be new, but I do not find any documentation to support my assumption. This was an assumption in a previous post a while back, but there wasn't any response. Any ideas? Thank you so much!
 

lcolborn

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The CPT book has the information on New vs. Established, not much but enough to give some guidance.
To answer your question, the patient would be an established patient to the new office/provider provided they are in the same specialty ( OB/Gyn ) and have been seen by the joining group within the last 3 years. Same goes for the new group that they have joined in, their patients would be established patient when
they see the new group that just joined in with the same specialty/subspecialty who belong to the same practice. ( New to each providers, but not new to the clinic/group, is the best way I can grasp this thing :) .

Hope this helps.
 

thomas7331

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I think the easiest way to look at it is this:
  • If the patient is seeing the same individual provider, then they are established if they were seen by that provider in the last three years - it doesn't matter if it was at the new or old practice.
  • If the patient is seeing a new provider, then they are established if they've seen another provider of that same specialty and under that same tax ID within the last 3 years.
In other words, when the provider joins the new practice, their existing patients that they bring over and continue to see will still be established. But if one of those patients was to see a different provider at the new practice for the first time, then they will only be established if they've been seen in that new practice before by someone else there with the same specialty.
 

dama002

New
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Addis, LA
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The question I have is if the doctor was billing with a group NPI and Tax Id and not individual would that matter?

for example at the old group the provider billed under the group and not individual and now will be filing under individual what would be the case in this senerio. Just curious.
 

csperoni

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Selden
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If the patient is seeing the same actual physician within 3 years, that is established no matter what group or individual billing situation you have, which I believe Thomas indicated in his first bullet point. It is professional services from the same physician OR another physician of same specialty in same group. It's been a long time since I needed to configure billing forms, but even if you are billing as a group, the individual who rendered the service is still on that claim form (box 24J).

From CMS E/M guide:
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.
 
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