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Use of a New Patient Office Visit Code

  1. Default Use of a New Patient Office Visit Code
    Exam Training Packages
    Can you code a new patient office visit when the patient has seen the provider at another group within the past three years....and that same provider fills in as a locums at our (different) group? So, the patient is new to the group, but not new to the provider. Thanks for your help.

  2. #2
    I would say No. The provider is familiar with the patient, regardless where they first met, now this is an established patient. I am not aware of any exceptions.
    Karolina, CPC, CPMA, CEMC

  3. #3
    If the provider saw the patient as a locum, meaning it was someone elses patient and billed under their provider number not his, then yes this would be a new patient to him.

    If he saw them under his own provider number anywhere else within the past three years, doesn't matter group or specialty, they would be established.

    Laura, CPC, CEMC

  4. #4
    Milwaukee WI
    Default Was new provider locum to YOUR practice
    For ease of examples / questions: Let's call them Dr New and Group Your

    1) Dr New saw patient at his/her previous office/group within the last 3 years, but patient has never been previously seen by anyone at Group Your.
    Established patient because seen by the provider within the last 3 years.

    2) Dr New saw patient at Group Your when Dr New was acting as locum tenens for Group Your. Dr New never saw patient at his previous group.
    Established patient because the patient has been seen by your practice in the last 3 years.

    3) Dr New saw patient at Group Other when Dr New was acting as locum tenens for Group Other. Dr New never saw patient at his previous OWN practice. Patient has never been seen by Group Your.
    I still think this is an Established patient because Dr New (even though Dr New's name wasn't on the bill) provided service to the patient within the last 3 years.

    I'm a little less certain about #3) than #1) and #2). I'm willing to listen to Laura's (and others') position on this.

    F Tessa Bartels, CPC, CEMC

  5. Default
    The patient will be an established patient for the provider for three years once the face-to-face service is rendered, no matter if it is the same hospital or a different one. The key here is "face-to-face"
    Jagadish, CCS-P, CPC

  6. #6
    North Carolina
    I have to agree with established. This is an unusual situation but since "face to face" is the key issue (as Jagadish pointed out), this is the driving force. It does make me wonder if the patient made an appointment with this physician since they had a patient/provider relationship already established. In any case, I would think that the carriers would view this as an established patient since the 3 rule year rule does apply.

  7. #7
    Default 3rd times the charm, I hope
    I can't get my response to post!!!

    The rules of new and established are thrown out in a locums situation.

    Per CPT

    "In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available."

    So use the flip side of our scenario.

    Patient is established with Dr. Smith. Patient moves an hour away, schedules an appointment with Dr. Jones. Dr. Jones breaks his leg takes some time off but he is in a solo practice. Has to bring in someone or he will lose his business. Calls his good buddy Dr. Smith.

    Even though this patient is established with Dr. Smith, per CPT she is to be billed as a new patient under Dr. Jones.

    Why would the reverse not hold true?

    Locum providers do not keep copies of records or schedules. Nothing is billed under them. How you could possibly sort out who is new and who it not is beyond me.

    I asked a healthcare attorney this question because I have a new provider. He was a resident so his services were billed under the teaching physician. Many of the patients in his practice followed him from his residency. The attorneys response was even though face to face service was provided it was not billed under him, these patients are new.

    This is my personal experience for what its worth.

    Laura, CPC, CEMC

  8. #8
    North Carolina
    I think this is one of those gray areas and may be one that is determined by the actual carrier. If we followed CPT's instructions...

    When one group provides coverage for another physician group, the patient encounter is classified as it would have been by the physician who is not available. For example, let's say your practice provides coverage for a solo physician in your community. While the physician is out of town, you see one of her patients. As long as the physician who is out of town has seen the patient in the last three years, you have to report the service using an established patient code. This is true even if you are unfamiliar with the patient, clinical information is not available and the office staff does not have basic demographic information.

    However...thinking from a CMS perspective, I don't think the scenario would produce the same result.

    Special considerations for Medicare patients

    A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but "professional service" is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate.

    I think this is one of those areas where you have to consider both guidelines and determine which one the carrier in question follows.

  9. Default
    Pt is NEW. Unless this pt was billed under the same specialty under the same tax id number, in the last three years, the pt is new.

  10. #10
    North Carolina
    If this is a Medicare patient, I disagree. Face-to-face is the key.

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