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New or Established?

  1. Default New or Established?
    Medical Coding Books
    A patient was sent to our out patient IR clinic by his oncologist to be seen by Dr. A for RF ablation of liver cancer on 5/19/09. Prior to this, Dr B inserted a tunneled catheter in the hospital on 3/6/09 and Dr C did a port check in the hospital. No E&M services were provided in the hospital. Drs A, B, and C are all in our group.

    So this visit in the IR clinic would be a new patient because he's there for a new condition and we've never done an E&M....is that right?

    Thanks,
    Diane Huston, CPC,RCC

  2. #2
    Location
    Columbia, MO
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    Default
    I say estb but I am interested in what others take is.

  3. #3
    Location
    North Carolina
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    3,126
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    I agree with you Michelle...Established.

    Definition of New Patient for Selection of E/M Visit Code

    Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

    30.6.7

  4. #4
    Default
    I agree, established, unless this doctor is a different specialty than the others.

    Laura, CPC

  5. Default
    I checked and Dr. A's subspeciality is cancer treatments. Drs B and C are neuroradiologists. Dr. A would never perform a neuro surgery and Drs. B and C would never perform the RF ablations or chemotherapy on cancer patients. Based on this then, it would appear to be a new patient?

    Diane

    P.S. Thanks for that link to the Medicare manual

  6. #6
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    Yes, it would be a new patient.

    Laura, CPC

  7. #7
    Location
    Columbia, MO
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    Not if all docs are in the same tax ID. then once they are seen by one doc they are established to the practice.

  8. #8
    Default
    You can have multiple specialties under one tax id#. If they are different specialties the same patient can be new multiple times under the same tax id#.

    Rebecca posted the guideline about same physician or specialty above.

    Laura, CPC

  9. #9
    Location
    Columbia, MO
    Posts
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    Yes it says same group practice.

  10. #10
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    "E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years."

    They specify it has to be from the same specialty in the group practice to be considered established.

    For instance, one of my family practice providers refers a patient to one of my cardiovascularthoracic surgeons, that is a new patient to the CVT even though they are billing under the same tax id.

    We even have an email from WPSMedicare stating they consider the CVT PAs to be different specialties from the CVT surgeons they work for.

    Laura, CPC

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