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New patient visit

  1. #11
    Medical Coding Books
    Thanks Donna!

    I am very detail oriented and just looked at the numbers so check this spin on the situation out.

    New patient visits require 3 of 3. How do you seperate out the exam elements for the problem and only count the medically necessary ones? Ok say you do that. You will probably be stuck with PF or EPF limiting you to a 99202 or 99201.

    If it is an acute problem say sinus infection, it shouldn't be hard to pull enough elements for a detailed history, its a new problem and they get an RX. An established patient would be a 99214, a new patient would be either 99202 or 99201 depending on exam. Reimbursement is higher on a 99214 than the 2 lowest level new patients.

    Based on cpts definiton I firmly believe new preventive/est problem is the correct way to code it, I just decided to look at the financial impact today.

    Laura, CPC
    Last edited by LLovett; 06-05-2009 at 09:42 AM.

  2. #12
    Duluth, Minnesota
    that IS interesting! .. even financially it makes sense! BUT - still, finacial impact aside, I still believe (and agree) that based on cpts definiton/guidelines- new preventive/est problem is the correct way to code it.
    Donna, CPC, CPC-H

  3. #13
    Seacoast- Dover New Hampshire
    I would be careful to check what the Chief Complaint is. I don't believe that providers can go looking for issues.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. #14
    I agree completely, this should be the exception not the rule when you have a new preventive appointment.

    I am from a rural area originally. Family practice doctors are few and far between. It is not uncommon to wait 2-3 months or longer to get established with one when you are a new patient. We would see this in that situation. They wait 3 months for an appointment and 3 days before they start getting sick, they show up for their well check to get established and mention they have a sinus infection.

    Laura, CPC

  5. #15
    Here is some food for thought:
    I wonder how this case unfolds. Did the patient initially come for the preventative exam and during the course of the visit a problem was discovered and then addressed in the process?
    Did the patient come because there was a problem and then it was decided to do the annual while s/he was there since it was about that time of year? Was the patient sent by another provider to continue care at the new practice/facility?
    I think in such split cases one must very carefully evaluate all aspects of the specific visit.
    I would reach out to the insurance and check what policies/procedures are in place (if any) for such situations.

  6. #16
    North Carolina
    I just have to ask...I understand you're concept of this encounter; however, how can you ignore the AMA's instructions in CPT?...Not to mention that some carriers DO follow these coding guidelines. I think it's wonderful that we can share our views/opinions but until the AMA changes their guidelines, I will follow their coding conventions........

  7. #17
    Columbia, MO
    The AMA had an article on their website about 6 months ago or so, which addressed this issue somewhat. In that they talked about the preventive, and oV on the same day. Their take on it was, first you must have two completely separate visit notes, then you may not duplicate any part of the history exam or decision making, the OV must be for something minor that can be addressed in the context of a 99212, because otherwise your patient is too ill to be subjected to a complete physical and is too ill to provide that base line that all other visits are judged against. I also agree with Rebecca regarding the guidelines.

  8. #18
    I don't see why you cannot have two new visits on the same day, especially when these exams are being done during the same appointment. The guidelines for new vs. established are based on years, and units of service are based on date of service.

    The argument for calling the patient established is based on the fact that the provider met him/her at the beginning of the appointment. How long after that did the patient become established? I'm inclined to think the following day based on the guidelines.

  9. #19
    Per CPT guidelines professional services are those face-to-face service rendered by a physician and reported by a specific CPT code.

    A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group or practice within the past three years.

    Where in the guidelines does it state you are new for a whole day? If that same patient is seen at 8am for a yearly and comes back after lunch with possible food poisoning is that 2nd visit new?

    Laura, CPC

  10. #20
    Duluth, Minnesota
    nice point again Laura...

    and Rebecca - I see your point of view also, but I don't think anybody is "ignoring" any's a matter of interpretation - and I guess I just interpret it that, if you're seen "once" for the intial visit whether that's the preventive service or sick/E/M service - AND then you are seen for something separate and another visit is charged - that second one is no longer "new" can it be if you've already been seen, you've now become established...

    I know when ever two new visits for the same patient by the same provider and or same specialty different provider have been billed,(here) one is always denied and (no so) oddly the denial reason is because the patient is not considered a "new" patient on that second visit coded.

    also - it is rare that there are two visit ..but it does happen.

    if you check out page 2 of the CPT 2009 professional edition - AMA - it's very clear in the decision tree ... if you can answer "no" - patient has not received service from the physician or another physician in group or same specialty within the last 3 years - then they are new.
    IF that patient has already had a preventive service ("new" based by that decision tree, because they had not been seen before it) how then, for the second "service".. the E/M, (prob/issue) can you answer no to it? using that same decision tree to determine new/est for that visit?, they'd be established, they've already recieved services from that provider
    Last edited by dmaec; 06-08-2009 at 03:47 PM. Reason: decision tree (I'll get my typos fixed eventually!) sheesh!!!
    Donna, CPC, CPC-H

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