Wiki New vs Established

Create Wiki
C

cmonarez

Contributor
Messages
14
Location
Santa Teresa, NM
Best answers
0
Hello, I have a question.
Currently we have a DO that is operating under his own NPI for a behavioral group, but now the group has added a new NPI for Family Practice under the same group. My question is , Will the patient be considered New or Established?
I know that the rule for new patient is 3yrs within the same practice, but billing under a new NPI be considered new?
Thank you in advance I really appreciate you rhelp.
 
Hi there, please review the chart in your CPT manual and guidance from CMS. New/established status is based on the provider/patient relationship not the practice/patient relationship. Any patients the DO has treated face-to-face in the past 3 years will be established.
 
Most insurances, especially Blue Cross, state that the claims follow the provider's NPI, not EIN. So if the patient was treated by the provider previously under that same rendering NPI, then the patient should be billed as Established. Otherwise, the 3 year applies.
 
You must log in or register to reply here.
Top