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New patient or established

  1. Default New patient or established
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    If a patient is seen in Family Practice and then changes to one of the FP/IM/Ped providers is this considered a new patient visit or an established patient visit? All providers are under the same tax id. In some cases the providers even work out of the same office. In the CPT guidelines it states specialty or subspecialty. Does Internal Medicine make this a different specialty? What if it is a child transferring from one Pediatric provider to another that is Ped/FM/IM?

  2. #2
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    In a multispecialty practice, a patient might be considered new even if they have received care from other physicians in the group and a medical record is available. The distinguishing factor here is the specialty designation of the provider.

    Example:

    • A patient who has been seen regularly by the pediatrician in your group.
    • The patient is now 18 years old and wants to transfer care to a family physician in the same group.
    • When she sees the family physician, she’ll qualify as a new patient because the family physician is in a different specialty than her previous physician.


    This is the case even though the family physician might be treating her for an existing problem and referring to her established medical record.
    Medicare has a list of specialty and sub-specialty designations.

    If the patient I going from Ped to Ped in the same group, it would be an established patient or Family Practice to Family Practice. Unless they are switching to the new provider in your example below because they are seeking internal medicine care, then it would be an established patient as the physicians are both Family Practice or both Pediatrician.
    Chelle Johnson, CPC CPMA CDEO CEMC CPCO CPPM AAPC Fellow
    Billing/Coding/Credentialing/Auditing Coordinator

    20+ years experience in Medical Billing and Auditing

  3. Default
    We are a multispecialty group. One of our physicians sees all ages ... He is Internal Medicine and Pediatrics...is a PCP for lots of patients. One patient will want to transfer from one of the Pediatricians to this provider. As he is also Internal Medicine he wants to bill as a new patient. I just need to understand if this is correct. Another example is a patient is seen in our after hours clinic then decides to establish with a provider. Our family practice provider has rendered a face to face and we know that this will not be a new patient visit if they go to another family practice provider in our group, but if they go to an internist is this a new patient? What rule applies to a Nurse Practitioner working under IM/Peds?

  4. #4
    Default
    • If the patient is switching from a Pediatrician to a Pediatrician/IM, then this is not a new patient.



    • For the after hours clinic, if the patient was seen by (for example) a family practice provider and then come in during regular hours to see a family practice provider then this is not a new patient either. The time or type of clinic is not the issue, but the specialty of the provider.



    • If the patient was seen by family practice provider and then is switching to an internist this is a different specialty and could be considered a new patient.



    • A nurse practitioner working under a pediatrician would be the same as the pediatrician. If new to the pediatrician then new to the NP. If established with the pediatrician then established with the NP.
    Chelle Johnson, CPC CPMA CDEO CEMC CPCO CPPM AAPC Fellow
    Billing/Coding/Credentialing/Auditing Coordinator

    20+ years experience in Medical Billing and Auditing

  5. #5
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    Internal Medicine is not a sub specialty of Pediatrics which is why it would be an established patient. Pediatric to Pediatric Orthopedics would be example of different specialty and sub specialty.
    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

  6. Default New VS Established
    My question is;

    We have a group of 10 Pediatric surgeons -
    If a patient comes to see one of our surgeons gets a consultation and has surgery. Then the following year the same patient comes to see one of other surgeons for a different diagnosis, so would we bill for a new consultation with a new diagnosis or an established E/M?
    My surgeons argue that they will bill a new consultation because its a new diagnosis.
    Please advise.

  7. #7
    Default
    Quote Originally Posted by igonzalez View Post
    My question is;

    We have a group of 10 Pediatric surgeons -
    If a patient comes to see one of our surgeons gets a consultation and has surgery. Then the following year the same patient comes to see one of other surgeons for a different diagnosis, so would we bill for a new consultation with a new diagnosis or an established E/M?
    My surgeons argue that they will bill a new consultation because its a new diagnosis.
    Please advise.
    If it the payer accepts consultation codes 99241-99245 and it meets Consultation requirements (The 3R's and not just a transfer of care for the condition), new vs established concept wouldn't apply as code description is "Office consultation for a new or established patient"

    If it does not meet definition of a consult or payer doesn't accept consult codes, then you cannot use new patient 99201-99205 and must use 99211-99215.
    Last edited by CodingKing; 10-11-2018 at 03:44 PM.
    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

  8. Default
    Also, remember this is based on primary specialty associated with the physician's NPI number. This is different than Taxonomy Codes.

    https://www.cms.gov/Research-Statist...yCodes2207.pdf

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