Question Performing a procedure or diagnostic test prior to New Patient Visit?

JessBojan

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Hello! This may have been answered somewhere but I couldn't find anything using the search. I am wondering what the best way to go about coding new patient visits when the provider has previously performed a procedure/diagnostic testing. We often get patients who schedule hysterosalpingogram or saline sono at their obgyns request due to issues conceiving. A lot of times after the doctor has performed the procedures and sent the results the patients obgyn will then refer them back to us for fertility treatment/options and they either see the same doctor who performed the procedure or another provider in our clinic. Once these patients return and our doctors perform a complete H&P and new patient visit, we aren't able to bill it as a new patient visit correct? Even though a new patient e&m hasn't been billed and the provider (or another provider in our office) has seen them solely to perform a procedure? I have been billing as established patient visits but I just want to be sure I am not missing anything.

Thanks for any advice or input!!
 

thomas7331

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A new patient is defined as one who has not had a face-to-face service with the provider (or other provider in the practice of the same specialty) in the prior three years. Generally speaking, surgical procedures are considered face-to-face services, but diagnostic tests and/or interpretations of the results and images are not. Individual payer policies, though, may vary on exactly which procedure codes will establish a patient with a provider and which will not.
 

csperoni

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Perhaps because I've only worked in specialties that don't perform diagnostic testing without first having an E&M, but I always interpreted new patient as having not received any service (in the 3 yr period by the same group, specialty). After reading the first response, I was curious so did some research. If the carrier follows CMS, a visit after a hysterosalpingogram or sono is considered a new patient visit.

I found this in the Medicare claims processing manual, Chapter 12, section 30.6.7:
Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Of course, as Thomas mentioned, some payors may have other policies regarding this.
 

JessBojan

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Perhaps because I've only worked in specialties that don't perform diagnostic testing without first having an E&M, but I always interpreted new patient as having not received any service (in the 3 yr period by the same group, specialty). After reading the first response, I was curious so did some research. If the carrier follows CMS, a visit after a hysterosalpingogram or sono is considered a new patient visit.

I found this in the Medicare claims processing manual, Chapter 12, section 30.6.7:
Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Of course, as Thomas mentioned, some payors may have other policies regarding this.
Thanks for finding this! The only thing that throws me off is because it states 'an interpretation of a diagnostic test' and yes the provider is interpreting it but he is also performing it not just reading the results.
 

JessBojan

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A new patient is defined as one who has not had a face-to-face service with the provider (or other provider in the practice of the same specialty) in the prior three years. Generally speaking, surgical procedures are considered face-to-face services, but diagnostic tests and/or interpretations of the results and images are not. Individual payer policies, though, may vary on exactly which procedure codes will establish a patient with a provider and which will not.
Thank you! I am going to see if I can find out if performing the diagnostic service has any effect due to the wording in the other reply I am not sure if it would still be considered a face-to-face visit. Obviously I know the provider is seeing the patient while performing the procedure, but I'm not sure how payers will follow. I just would hate to be losing out on revenue because I am billing an established visit and not fighting denials on the new patient visits. I appreciate your help!
 
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