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New/Est within same practice

  1. Default New/Est within same practice
    Exam Training Packages
    We have a group practice with 3 ENT's and 1 Dermatologist. My Doctors want to see some documentation regarding the guidlines on how to bill new vs established if a patient sees more than one doc in our practice for differant conditions. the three year rule keeps popping up when we code new patient in the following example.
    For example if one of our doctors sees a patient for a ear problem (this doc is ent/neurotology) one year and then the next year sees one of our other Docs for the first time for a thyroid problem can the second doc that treated for the thyroid code a New Patient Exam.
    All of our Docs have the same Group NPI and use the same Tax ID but of course have individual NPI's that appear on the claim.
    If anyone can offer guadiance and also where i can find documentation that would be great.

  2. #2
    The best resource is the CPT books Decision Tree for New vs Established Patients under the E/M guidelines.

    It is based on same group/same specialty. So how your providers are credentialed is how you determine new or established.

    It doesn't matter what the issue is they are treating just if they are of the same specialty in the same group.

    Laura, CPC, CEMC

  3. Default
    Thank You!

  4. Default new vs. est
    can someone advise where i can find medicares guidlines on this matter. My Doctors want to see it. Thank You

  5. #5
    North Carolina
    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.

    Section 30.6.7

  6. #6
    Wink hi ear
    the most recent material is in CODING EDGE October, 2009 and it includes some material that is relavant to levels of E/m. There's a quote from a former medical director of HCFA (ie: CMS) ,,,,
    actually, upon re-reading, I realized that it is focused on the levels that a doctor may bill in cases where the the patient has a 'new' is still interesting though. Hope I haven't sent anyone chasing geese!

    Last edited by Jamesmmm; 01-13-2010 at 11:36 AM. Reason: new info

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