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Would like opinions please.

  1. #1
    Default Would like opinions please.
    Medical Coding Books
    We have a physician who was in practice by himself (Dr. A). Other Doc's here cover for each other on call (Dr B and Dr C). So, in this instance Dr. B covered a hospital visit call in July and charged appropriate subsequent visit CPT. Now, in August, Dr. A is not with the facility any longer and patient is now with Dr. B. Dr. B charged a new patient visit when patient came to establish care.
    My thinking is that this is inappropriate because they have already charged on this patient within the past month, they can no longer be considered a new patient. The office charged the patient a new visit.
    We're in discussions and it's very confusing and muddy!!! Any comments appreciated. Thanks

  2. Default
    The patient received 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. It should have been billed as an established patient.

  3. Default
    This same issue came up in our office within the past month. If a patient was
    seen by another physician within your same practice, the patient is an
    established patient (was seen within the past three years).

  4. #4
    Default
    Ok I'm a bit confused, but I'll take a shot at it.

    The patient was seen by a provider while they were part of your group, therefore establishing them with that specialty in that group.

    This provider left. A remaining partner in the group of the same specialty took over the patient. This would be an established patient.

    The other way I am seeing this is that the patient was established with an external practice and one of your providers covered for that external provider. Then the patient decided to see your group instead of their original provider, and your provider wants to bill a new patient.

    How was the subsequent care day billed? If it was billed under your provider this patient is established. If it was billed under the external provider with a Q5 modifier, I would say this is a new patient.

    There is another thread about locum tenens with a lot of info and differing veiws, but this is a similar situation. You may need to check with your carrier if this was a reciprocal billing situation.

    I just love muddy waters....not!

    Laura, CPC, CEMC

  5. #5
    Default opinions
    Quote Originally Posted by katmryn78 View Post
    Ok I'm a bit confused, but I'll take a shot at it.

    The patient was seen by a provider while they were part of your group, therefore establishing them with that specialty in that group.

    This provider left. A remaining partner in the group of the same specialty took over the patient. This would be an established patient.

    The other way I am seeing this is that the patient was established with an external practice and one of your providers covered for that external provider. Then the patient decided to see your group instead of their original provider, and your provider wants to bill a new patient.

    How was the subsequent care day billed? If it was billed under your provider this patient is established. If it was billed under the external provider with a Q5 modifier, I would say this is a new patient.

    There is another thread about locum tenens with a lot of info and differing veiws, but this is a similar situation. You may need to check with your carrier if this was a reciprocal billing situation.

    I just love muddy waters....not!

    Laura, CPC, CEMC
    Thanks Laura, and all others who responded. Okay, to answer, it was your second scenario, it was a physician by himself (Dr. A), our physician (Dr. B) covered for him and the patient was billed under Dr. B as a subsequent visit. I did see the other thread concerning the similar scenario after I posted this. So, I recommended to the office that the patient should have been billed as an established and this conversation ensued. I think we have had about 5 emails and at least 2 phone calls and about 5 people involved. It is very muddy isn't it? Just when you think you have it straightened out, someone else asks a question!!!! LOL.
    Thanks again everyone! This always helps me, even if we don't always agree, but it seems on this one, that we do!!

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