Wiki Psychotherapy services/Medical Services same practice

[khollinger]

Hello!

I work for a mental health agency that also provided medical services (medication determination, etc) I have heard conflicting information in regards to the new patient vs established patient for the medical department.

If the client has been seen for any mental health services in the past 3 years and then is opened to the medical department would that be considered a new patient? I have an insurance company that is denying new patient charges for the above reason. According to what my medical department is telling me they should always bill as a new patient if the client has not been seen for medical services in the past 3 years, even if they have received Mental health services (Psychotherapy charges. etc).

Any input would be apprecciated

 

[thomas7331]

The rule, per CPT, is that if the patient is new to the group AND specialty in the past three years, then the patient should be considered new. So in theory, if your mental health provider has a different specialty from you medical provider, then they would be new if they had not seen the medical provider in three years. In practice, however, different payers classify provider specialties differently, so it can sometimes be a guessing game to try to know what specialty your payer is considering any given provider. For example, Medicare uses the provider's specialty that they declare on the CMS enrollment form as the specialty, whereas some commercial payers look at the provider's primary taxonomy code on the NPI registry to determine the specialty. And then still other payers will create their own internal systems for identifying a specialty. So really your only solution to this will be to look at your payers' policies, or contact them for additional information. I know too that some large practices adopt an internal policy to consider a patient established if they have been seen by anyone in the group regardless of specialty simply because it can become too time-consuming to try to customize the coding to each and every payers' particular needs.