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Thread: New vs. Established in a Sort-of not a Group

  1. #1

    Unhappy New vs. Established in a Sort-of not a Group

    AAPC: Back to School
    Hello my coding friends,

    I just cannot seem to be able to convey my opinion properly to our physicians in regard to this situation and I am hoping someone can help shed some light. Let's see if I can put it all down here and anyone can help me to communicate or tell me that I'm flat out wrong.

    I just started billing for a practice which has 3 (same specialty) docs that DO NOT bill as a group practice (they each have other practices in other locations which are not linked at all to this location). The office and nursing staff are shared between them as well as the actual office space, charts, scheduling system etc. They bill and get paid separately and then put a certain percentage into the "Group" fund to pay the location expenses and salaries.

    This has just been a complete logistical nightmare and I would love to be able to convince them that they need to get together under a group in order to have the appropriate checks and balances (don't even get me started on how bad "sharing" EOB remittances between 2 offices has been). But that's not my actual problem.

    My issue is that upon beginning to review their billing, I noticed that they were billing a New Patient Office Visit for Dr. B even though Dr. A saw the patient 6 months ago (whether it is a F/U or new problem). I explained that since there is 1 chart for the patient which is shared and accessible by both docs that this should be an Established Visit. Their thought process was that because THEY never actually saw the patient themselves and they are not billing as a group and each doc is never in the office with another at the same time (they alternate weeks/days in the office) that they can bill for a New Visit.

    For some reason I cannot find anything that neither supports nor denies their situation and I'm at my wits end. Fortunately I am not yet involved in the actual billing so I have not had to worry about 'doing the right thing' myself but eventually I will and I need to know if I am out of line before I refuse to code this way.

    Any advice or assistance would be greatly appreciated.

  2. #2
    Join Date
    Apr 2007
    Reading, PA


    If by what I am ready they do not have the same tax id number?

    If pt sees Dr A as a new pt then goes to Dr. B as a new pt that is correct since the provider are not of the same tax id numbers.

    Once the providers fall under the same tax id number that is when the pt would be billed by Dr B as established.

  3. #3

    Default Really???

    You are correct in that they are not using the same Tax ID when billing. So I guess I am wrong and this is a way to get around the system. Of course in my eyes, it costs more in work hours and I don't believe it's the right thing to do, but at least I would be following the rules.
    Thanks for your input.

  4. #4
    Join Date
    Apr 2007


    I agree, they would be new patients since they are not in the same group. I have a similar setup with one of my peds providers, he is located in an office with 2 others, they share everything but the tax id.

    One thing you need to watch for though, if they are seeing this patient under a covering situation then it would not be appropriate to charge a new patient. If you look in CPT under the E/M guidelines where they describe new vs established there is a paragraph dealing with covering providers.

    I know that just made it more complicated but doing things correctly isn't always easy.

    Good luck,

    Laura, CPC, CEMC

  5. #5

    Default Thanks!

    Thanks for your wisdom Laura.
    Fortunately for me- if things weren't complicated sometimes, I don't think I would have much of a job. Ha Ha

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