Can you code a new patient office visit when the patient has seen the provider at another group within the past three years....and that same provider fills in as a locums at our (different) group? So, the patient is new to the group, but not new to the provider. Thanks for your help.
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Use of a New Patient Office Visit Code
- Thread starter maclou
- Start date
Karolina
Guru
I would say No. The provider is familiar with the patient, regardless where they first met, now this is an established patient. I am not aware of any exceptions.
If the provider saw the patient as a locum, meaning it was someone elses patient and billed under their provider number not his, then yes this would be a new patient to him.
If he saw them under his own provider number anywhere else within the past three years, doesn't matter group or specialty, they would be established.
Laura, CPC, CEMC
If he saw them under his own provider number anywhere else within the past three years, doesn't matter group or specialty, they would be established.
Laura, CPC, CEMC
FTessaBartels
Guest
Was new provider locum to YOUR practice
For ease of examples / questions: Let's call them Dr New and Group Your
1) Dr New saw patient at his/her previous office/group within the last 3 years, but patient has never been previously seen by anyone at Group Your.
Established patient because seen by the provider within the last 3 years.
2) Dr New saw patient at Group Your when Dr New was acting as locum tenens for Group Your. Dr New never saw patient at his previous group.
Established patient because the patient has been seen by your practice in the last 3 years.
3) Dr New saw patient at Group Other when Dr New was acting as locum tenens for Group Other. Dr New never saw patient at his previous OWN practice. Patient has never been seen by Group Your.
I still think this is an Established patient because Dr New (even though Dr New's name wasn't on the bill) provided service to the patient within the last 3 years.
I'm a little less certain about #3) than #1) and #2). I'm willing to listen to Laura's (and others') position on this.
F Tessa Bartels, CPC, CEMC
For ease of examples / questions: Let's call them Dr New and Group Your
1) Dr New saw patient at his/her previous office/group within the last 3 years, but patient has never been previously seen by anyone at Group Your.
Established patient because seen by the provider within the last 3 years.
2) Dr New saw patient at Group Your when Dr New was acting as locum tenens for Group Your. Dr New never saw patient at his previous group.
Established patient because the patient has been seen by your practice in the last 3 years.
3) Dr New saw patient at Group Other when Dr New was acting as locum tenens for Group Other. Dr New never saw patient at his previous OWN practice. Patient has never been seen by Group Your.
I still think this is an Established patient because Dr New (even though Dr New's name wasn't on the bill) provided service to the patient within the last 3 years.
I'm a little less certain about #3) than #1) and #2). I'm willing to listen to Laura's (and others') position on this.
F Tessa Bartels, CPC, CEMC
RebeccaWoodward*
True Blue
I have to agree with established. This is an unusual situation but since "face to face" is the key issue (as Jagadish pointed out), this is the driving force. It does make me wonder if the patient made an appointment with this physician since they had a patient/provider relationship already established. In any case, I would think that the carriers would view this as an established patient since the 3 rule year rule does apply.
3rd times the charm, I hope
I can't get my response to post!!!
The rules of new and established are thrown out in a locums situation.
Per CPT
"In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available."
So use the flip side of our scenario.
Patient is established with Dr. Smith. Patient moves an hour away, schedules an appointment with Dr. Jones. Dr. Jones breaks his leg takes some time off but he is in a solo practice. Has to bring in someone or he will lose his business. Calls his good buddy Dr. Smith.
Even though this patient is established with Dr. Smith, per CPT she is to be billed as a new patient under Dr. Jones.
Why would the reverse not hold true?
Locum providers do not keep copies of records or schedules. Nothing is billed under them. How you could possibly sort out who is new and who it not is beyond me.
I asked a healthcare attorney this question because I have a new provider. He was a resident so his services were billed under the teaching physician. Many of the patients in his practice followed him from his residency. The attorneys response was even though face to face service was provided it was not billed under him, these patients are new.
This is my personal experience for what its worth.
Laura, CPC, CEMC
I can't get my response to post!!!
The rules of new and established are thrown out in a locums situation.
Per CPT
"In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available."
So use the flip side of our scenario.
Patient is established with Dr. Smith. Patient moves an hour away, schedules an appointment with Dr. Jones. Dr. Jones breaks his leg takes some time off but he is in a solo practice. Has to bring in someone or he will lose his business. Calls his good buddy Dr. Smith.
Even though this patient is established with Dr. Smith, per CPT she is to be billed as a new patient under Dr. Jones.
Why would the reverse not hold true?
Locum providers do not keep copies of records or schedules. Nothing is billed under them. How you could possibly sort out who is new and who it not is beyond me.
I asked a healthcare attorney this question because I have a new provider. He was a resident so his services were billed under the teaching physician. Many of the patients in his practice followed him from his residency. The attorneys response was even though face to face service was provided it was not billed under him, these patients are new.
This is my personal experience for what its worth.
Laura, CPC, CEMC
RebeccaWoodward*
True Blue
I think this is one of those gray areas and may be one that is determined by the actual carrier. If we followed CPT's instructions...
When one group provides coverage for another physician group, the patient encounter is classified as it would have been by the physician who is not available. For example, let's say your practice provides coverage for a solo physician in your community. While the physician is out of town, you see one of her patients. As long as the physician who is out of town has seen the patient in the last three years, you have to report the service using an established patient code. This is true even if you are unfamiliar with the patient, clinical information is not available and the office staff does not have basic demographic information.
However...thinking from a CMS perspective, I don't think the scenario would produce the same result.
Special considerations for Medicare patients
A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but "professional service" is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate.
I think this is one of those areas where you have to consider both guidelines and determine which one the carrier in question follows.
http://www.aafp.org/fpm/20030900/33unde.html
When one group provides coverage for another physician group, the patient encounter is classified as it would have been by the physician who is not available. For example, let's say your practice provides coverage for a solo physician in your community. While the physician is out of town, you see one of her patients. As long as the physician who is out of town has seen the patient in the last three years, you have to report the service using an established patient code. This is true even if you are unfamiliar with the patient, clinical information is not available and the office staff does not have basic demographic information.
However...thinking from a CMS perspective, I don't think the scenario would produce the same result.
Special considerations for Medicare patients
A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but "professional service" is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate.
I think this is one of those areas where you have to consider both guidelines and determine which one the carrier in question follows.
http://www.aafp.org/fpm/20030900/33unde.html
GR8CPC
New
Pt is NEW. Unless this pt was billed under the same specialty under the same tax id number, in the last three years, the pt is new.
RebeccaWoodward*
True Blue
If this is a Medicare patient, I disagree. Face-to-face is the key.
RebeccaWoodward*
True Blue
If a visit was reported from his practice, then a face to face is established. If he provides a locum service for another group, the fact that he has already reported his services from his home pratice and has face to face visits, within the last 3 years, makes this patient established. Face to face is the definition...locum, separate group, etc doesn't define this patient.
Betsy Nicoletti
Guest
Patient is established
The CPT and Medicare definitions are very clear on this: if the patient has had a professional service with that physician----don't go any farther and make it too hard. The answer to that is yes, so the patient is established.
The fact that you were paid as if the patient was new isn't surprising: the locum's number has only recently been on the claim form. The payer had no way of knowing that the physician who was seeing the patient was the patient's own physician from the claim submitted with the Q6 modifier.
Doctors should be careful with this: yes, you can get it paid that way if the payer's system isn't set up correctly.
No, you may not get to keep the money.
The CPT and Medicare definitions are very clear on this: if the patient has had a professional service with that physician----don't go any farther and make it too hard. The answer to that is yes, so the patient is established.
The fact that you were paid as if the patient was new isn't surprising: the locum's number has only recently been on the claim form. The payer had no way of knowing that the physician who was seeing the patient was the patient's own physician from the claim submitted with the Q6 modifier.
Doctors should be careful with this: yes, you can get it paid that way if the payer's system isn't set up correctly.
No, you may not get to keep the money.
RebeccaWoodward*
True Blue
I will chuck this up to...agree to disagree, agreeably.
Sounds like a plan Rebecca.
I don't like to argue but I deal with a lot of locums and if we are doing it wrong I really do want to know myself. They make things so difficult on purpose! I guess I will have to trust our attorneys...sigh.
Have a great weekend everyone!
Laura, CPC, CEMC
I don't like to argue but I deal with a lot of locums and if we are doing it wrong I really do want to know myself. They make things so difficult on purpose! I guess I will have to trust our attorneys...sigh.
Have a great weekend everyone!
Laura, CPC, CEMC
RebeccaWoodward*
True Blue
I don't view this as arguing...I like to think of it as a "healthy discussion". I have emailed my Medicare carrier for their stand on this issue. When I receive their response, I'll post it.
RebeccaWoodward*
True Blue
I received a phone call from our local Medicare carrier this morning. Per Fran, the key to this scenario is face-to-face. She did reference a FAQ from a recent publication...
"Can the physician bill for a new patient exam if he/she leaves a practice for a new one and the Medicare patient comes to the new office to see that particular physician?"
"No. The phrase "new patient" means that a patient has not received any professional services (i.e. evaluation and management) or other face-to-face services (i.e. surgical procedure) from the physician or physician group (same physician specialty) within the last three years."
Now...I realize we are speaking of a locum tenen situation and her statement was that this was irrevelant. The question and answer was meant to remain "vague" so that there was not a misconception of what constituted new v/s established. I also refered to the citation in CPT regarding the "on call/covering situation" and again...she stated this was irrevelant since Medicare determines new versus established based on face-to-face services within a 3 year time frame (same specialty).
Now that I have a confirmation from my carrier on this view, I would recommend that you contact your carrier if this could be an issue for you. My carrier was very clear that a recoupment request would be issued upon discovery of this type of error.
"Can the physician bill for a new patient exam if he/she leaves a practice for a new one and the Medicare patient comes to the new office to see that particular physician?"
"No. The phrase "new patient" means that a patient has not received any professional services (i.e. evaluation and management) or other face-to-face services (i.e. surgical procedure) from the physician or physician group (same physician specialty) within the last three years."
Now...I realize we are speaking of a locum tenen situation and her statement was that this was irrevelant. The question and answer was meant to remain "vague" so that there was not a misconception of what constituted new v/s established. I also refered to the citation in CPT regarding the "on call/covering situation" and again...she stated this was irrevelant since Medicare determines new versus established based on face-to-face services within a 3 year time frame (same specialty).
Now that I have a confirmation from my carrier on this view, I would recommend that you contact your carrier if this could be an issue for you. My carrier was very clear that a recoupment request would be issued upon discovery of this type of error.
RebeccaWoodward*
True Blue
Duing a random audit? Maybe they find these claims by requesting the locum tenen files. Since the regular physician must keep on file a record of each service along with the locums NPI, this would leave an audit trail.
josemen07@yahoo.com
Guest
Good Morning Laura,
This is something that has come up a few times and I've been told the same in the past. But upper management has asked me to provided documentation supporting this.
Where can I physically find this information so I can pass on to upper management. Please advise.
Thank you
Jose, CPC, CPMA
josemen07@yahoo.com
Guest
New Vs Established
If a provider is new to our group and sees a patient he has seen before at the previous group, would this visit be billed new or established. And where can I find supporting documentation to back up the answered. I have been asked by upper management to acquire this information and present to them. Please advise.
Thank in advance
Jose Mendieta
If a provider is new to our group and sees a patient he has seen before at the previous group, would this visit be billed new or established. And where can I find supporting documentation to back up the answered. I have been asked by upper management to acquire this information and present to them. Please advise.
Thank in advance
Jose Mendieta