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New patient code denied by Medicare

  1. #1
    Default New patient code denied by Medicare
    Medical Coding Books
    We are a professional office; billing as a group for our Providers (physicians)
    We have a Brand New Patient that has never been to "our" office before...Medicare recently denied the new patient office visit code for frequency of services.
    Turns out, our Provider also saw this patient in his private practice within the last three years. Medicare says if the same Physician sees a patient in his private office and then again through our clinic, even though we are billing under a different NPI, we cannot bill it as a new patient, but rather we have to bill it as an [I]established[I] patient.
    I re-read the E&M Guidelines, and I still do not see it that way, maybe I am not interpreting it correctly:
    "A new patient is one who has not received any professional srvs from the physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years."
    Am I CRAZY, or does this guideline refer to physicians within the same group practice only?

  2. #2
    Dover Seacoast New Hampshire
    Medicare is correct.

    The new patient rule is provider specific...not always practice specific. The new patient codes are designed to give extra credit for the work done seeing patients that the PROVIDER has not seen before or within three years. Just because he switches practices, doesnt meant that all the patients he has seen in the practice are new to him.

    Page 5 of the AMA's CPT Professional Edition has a flow chart. It's confusing, but essentially reads "has a patient received any professional service from the physician OR "Has a patient received any professional service from another physician in the group?" Be careful not to combine those two sentences to assume that the new patient is new when they are seen in a new group.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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