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Use of a New Patient Office Visit Code

  1. #11
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    Medical Coding Books
    Actually Rebecca, based on your posting the key would be was a face to face service reported in the last 3 years?

    In the case of a locum, it is not reported under their number so the answer would be no.

    Laura, CPC, CEMC

  2. #12
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    If a visit was reported from his practice, then a face to face is established. If he provides a locum service for another group, the fact that he has already reported his services from his home pratice and has face to face visits, within the last 3 years, makes this patient established. Face to face is the definition...locum, separate group, etc doesn't define this patient.

  3. Default Patient is established
    The CPT and Medicare definitions are very clear on this: if the patient has had a professional service with that physician----don't go any farther and make it too hard. The answer to that is yes, so the patient is established.

    The fact that you were paid as if the patient was new isn't surprising: the locum's number has only recently been on the claim form. The payer had no way of knowing that the physician who was seeing the patient was the patient's own physician from the claim submitted with the Q6 modifier.

    Doctors should be careful with this: yes, you can get it paid that way if the payer's system isn't set up correctly.

    No, you may not get to keep the money.
    Betsy Nicoletti, M.S., CPC
    www.codapedia.com

  4. #14
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    Refer to CPTs guideline on how to handle the instance where a physician is on call or covering for another physician.

    Laura, CPC, CEMC

  5. #15
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    North Carolina
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    I will chuck this up to...agree to disagree, agreeably.

  6. #16
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    Sounds like a plan Rebecca.

    I don't like to argue but I deal with a lot of locums and if we are doing it wrong I really do want to know myself. They make things so difficult on purpose! I guess I will have to trust our attorneys...sigh.

    Have a great weekend everyone!

    Laura, CPC, CEMC

  7. #17
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    North Carolina
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    I don't view this as arguing...I like to think of it as a "healthy discussion". I have emailed my Medicare carrier for their stand on this issue. When I receive their response, I'll post it.

  8. #18
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    North Carolina
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    I received a phone call from our local Medicare carrier this morning. Per Fran, the key to this scenario is face-to-face. She did reference a FAQ from a recent publication...

    "Can the physician bill for a new patient exam if he/she leaves a practice for a new one and the Medicare patient comes to the new office to see that particular physician?"

    "No. The phrase "new patient" means that a patient has not received any professional services (i.e. evaluation and management) or other face-to-face services (i.e. surgical procedure) from the physician or physician group (same physician specialty) within the last three years."


    Now...I realize we are speaking of a locum tenen situation and her statement was that this was irrevelant. The question and answer was meant to remain "vague" so that there was not a misconception of what constituted new v/s established. I also refered to the citation in CPT regarding the "on call/covering situation" and again...she stated this was irrevelant since Medicare determines new versus established based on face-to-face services within a 3 year time frame (same specialty).

    Now that I have a confirmation from my carrier on this view, I would recommend that you contact your carrier if this could be an issue for you. My carrier was very clear that a recoupment request would be issued upon discovery of this type of error.

  9. #19
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    How do they determine if there was a face to face service this in a locum situation?

    I know they are proposing adding the locums info to the claims but as of now (as far as I know anyway) it is not required.

    Laura, CPC, CEMC

  10. #20
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    Duing a random audit? Maybe they find these claims by requesting the locum tenen files. Since the regular physician must keep on file a record of each service along with the locums NPI, this would leave an audit trail.

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