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New vs. Established and WC

  1. Default New vs. Established and WC
    Medical Coding Books
    Hi everyone,
    We are getting conflicting info in our office on this and could use some input from you experts! Scenario is a patient who has only been seen in our ortho office for a WC claim. The case is closed and the patient has come back in under private insurance or self pay for a different problem. There has been an 8 month lapse since he was last seen here under WC. Can we charge him a new patient visit or would he be established? Also, along the same lines, but hypothetically, if he came in with a second WC claim some time later, different from the problem we had originally seen him for, would he be new then or still established? Any clarification you can give would be appreciated! I'm in NC.
    Thanks so much,

  2. #2
    As far as I know the new and established patient guidelines are not payer specific. Once a doctor has provided face to face care that is reported by a specific CPT code they are coded as established until the 3 year criteria is met.

    Laura, CPC

  3. #3
    I say established.

    If you are billing workman's comp with CPT codes, you should adhere to the CPT guidelines. Just because his private insurance technically hasn't seen a "new patient CPT code" doesn't mean they aren't established to your practice already. You should follow the 3 year new patient rule.

  4. #4
    North Carolina
    I, too, live in NC. Here's our WC link

    New Patient
    A new patient is one who is new to the physician or an established patient with a new industrial injury or condition. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury, or illness.

    Established Patient

    An established patient is a patient who has been seen previously for the same industrial injury or illness by the physician.

    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.

    No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

  5. #5
    and of course... a state law overrides us!!!

    Thanks Rebecca

  6. #6
    North Carolina

    Too North Carolinians can be famous for that.................

  7. #7
    lol... hows Virginia for ya...

  8. #8
    Milwaukee WI
    Default WC vs other insurance
    I'm not sure if I understand the original post correctly, but I think the scenario is:
    Patient had WC injury - now resolved; 8 months later patient comes to same physician with a complaint that will be covered under patient's regular insurance.
    In this case the patient is established. Think of it this way - If s/he had changed insurance companies from the first visit to the second visit you wouldn't bill a "new" patient visit because no claim had gone to that insurance company ...

    Now, as Rebecca points out, there may be differences with WC claims as per your state laws/regulations. So it's important to know those guidelines.

    Hope this helps.

    F Tessa Bartels, CPC, CEMC

  9. Default thanks!
    Thanks as always to all you helpful folks!

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