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Denial for 99204 New vs Established

  1. Question Denial for 99204 New vs Established
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    We have received a denial for E/M code 99204 from a managed care plan stating that the patient was an established patient based on a Diagnostic Assessment 90791, 90785 we did about 10 days prior to the E/M.

    My provider wants me to appeal based on the clip from the CMS guide to billing E/M: New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years.

    We are a mental health organization and he states that since our providers are not "physicians" then they cannot use the diagnostic assessment as a previously professional services. I have argued that the diagnostic assessment was an encounter and therefore makes this patient established. How can I appeal something that I think is incorrect.

    Am I wrong in this matter and should I still appeal?

  2. #2
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    Who billed for the 90791, 90785? If its same provider billing for the E&M its established. If its a different provider and different specialty then E&M would be new patient
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

  3. #3
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    Quote Originally Posted by CodingKing View Post
    Who billed for the 90791, 90785? If its same provider billing for the E&M its established. If its a different provider and different specialty then E&M would be new patient
    Agreed, if the patient was seen by the same provider who did 90791/90785, and within 3 years, then the E/M visit is an Established Visit. Same if the provider is from that provider's department/specialty.
    If the provider was different than the provider who performed 90791/90785, and haven't seen the patient before (or after 3 years), or from a different department/specialty, then the visit could be New Patient.

    Noridian (my local MAC):

    New Patient
    Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.

    Established Patient
    Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.


    Whether the provider is a physician or not, does not matter in terms of determining New vs. Established patient status. Any Face-to-Face encounters count towards the above criteria.


    Hope that helps!
    Last edited by Pathos; 08-13-2018 at 04:16 PM. Reason: Clarification
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

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