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New vs Established

  1. #1
    Default New vs Established
    Medical Coding Books
    I understand the three year rule and physicians of the same specialty. However, I am also told that when it comes to a "New" visit, that they group FP, IM, and GP all together. So if a patient sees our FP, and then a year later sees an IM doc for the first time, the IM doc cannot bill a "New"
    Is that correct, and if so, can you point me to the supporting docs?

  2. #2
    You are allowed and should be paid by the insurance a new patient rate when they see a physician in the same group "who is a different specialty". What we have learned over our years, as a multi-specialty/FP/IM group, is that Internal Med is not considered a specialty as Ortho or OBGYN would. If an FP has referred their patient to the Internist and they are in the same group the insurance company will not recognize the designation of Internal Med as a specialist but instead a PCP. We see this with our insurance companies...they apply a copay of a PCP not a specialist when patients are treated by an Internal Med physician-which in reality is exactly the case for our patients. The internal med is their PCP not a specialist treating only specific conditions.

  3. #3
    Default New Established
    Thank you for the info. Have you found that Medicare also applies this rule, or do they treat them both as distinct specialties, and allow New for both? I see that the Specialty list from CMS does define both of them as distinct specialties.

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