Wiki Patient seen under Worker's Comp, now coming in for the first time as a standard sick office visit, are they new or established?

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kkeller1125

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Hello!

Here's my situation. A patient who has never been seen by our clinic comes in for a Worker's Comp injury. Per Worker's Comp, each initial visit for a new injury is billed as a new patient code....My question is, does it work the other way? If they later come to see us due to a non-work related illness, are they technically established already, or does it count as a new patient visit since we've never seen them outside of Worker's Comp?

In my mind I think of WC as it's own beast unrelated to any other insurance, but I'm not sure if that's the correct mindset.

Thanks!
 
Hi there, interesting question. The CPT guidelines for new/established are based on whether a physician/QHP has rendered a face-to-face service within the three year period, not the patient's coverage. I would check the individual payer's policy to see if they add something more, but my hunch is payers won't want to pay for a new patient visit if they can avoid it.
 
I agree, the payer is irrelevant - code choice should be based on whether or not the provider has seen the patient face-to-face within three years. New patient codes are only used when the patient is new to the provider because of the additional work and cost to the practice involved in registering the patient, building a medical record, obtaining a complete history, etc. A change of coverage for the patient does not make the patient new again.
 
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