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New vs Estab Patient

  1. Default New vs Estab Patient
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    An insured individual had a break in coverage with the insurance company. The member went and saw an eye doctor and the records state the patient is returning to the clinic for an annual exam. The provider originally submitted the code 99214 for the visit of an established patient, and then submitted a corrected claim with a 99204 for a new patient. Whereas the member's claim history does not go back past 3 years as the member has not been covered for an extended period of time. Would they still be considered an established patient due to what is documented, or could they be a new patient due to the fact that the insurance company and no 3 year history?

  2. #2
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    It does not matter if patient has break or switches insurance that does not trigger a new 3 year period. Even if the new payer doesn't know of the past visits it would still be a false claim to bill as new when you know they are established based off the 3 year rule. If the patient is knowledgeable enough they may complain to the payer and put at risk of an audit.
    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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    Noridian (local MAC) says:

    "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."

    As CodingKing mentioned, coverage has nothing to do whether the patient is considered New or Established. The only deciding factor is whether the patient was seen face-to-face by the provider/department within the 3 year threshold period. Based on what you are sharing, it sounds like the provider goofed up and should probably retract the corrected claim, or do a second corrected claim in order to stay within compliance.
    Last edited by Pathos; 09-06-2018 at 05:16 PM. Reason: Linky
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  4. Default
    Thank you for the wonderful feedback!!!

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