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New Patient vs Established compliance

  1. #1
    Default New Patient vs Established compliance
    Medical Coding Books
    I have a new provider coming to our practice. Because he is coming for a different speciality group, I know I can bill his patients as a new patient (99205-99201) if he documents appropriately. My question is does it matter (legal?, compliance?) if some patients are billed as new patient and some as established. The provider may not have time or decide not to do a full H & P so I would not be able to bill a new patient code.

    Also, I would appreciate any feedback on how to explain to patient's that we can bill for a new patient visit even though they have seen this provider for years, just at with a different group. Patients see the higher charge on their EOB's and get a little upset.

    Thank you.

  2. #2
    New Windsor, New York
    All that really matters is if the code selected is apporpriate for the type of patient and if the documenation supports the use of the code. I am curious as to why you would say you cannot bill a new patient if the doctor didn't have time to do a "full" exam. As long as there is one exam element documented, that would count as an exam and you would have 99201. Unless this physician is doing rounds at the hospital and as such cannot bill for an initial inpatient visit.

    Also, keep in mind that regardless of which practices the doctor saw the patient at, the rule for established patient is that where the provider has provided services to the patient with the last three years. Therefore, this would be an established patient to the doctor - just not to the practice, and as such, he or she probably would not perform the full exam that a new patient recieves. Again, as long as all of the documentation and patient status fulfill the requirements, you can use that code.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  3. Default
    The last practice I worked for also brought in a provdier from a different group (same specialty). To reitierate what MnTwins said, if the patient are not new to the doctor - they have been seen before in the last group where the doctor practiced - they you would be required to bill them as established patients. You can only bill as new if they are new to the practice and to the doctor.

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