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New patient vs established patient

  1. #1
    Thumbs up New patient vs established patient
    Clearnace Sale
    A patient who was not having coverage from any insurance has taken medical service by a provider and paid in cash at that time. After few months, the same patient takes medical service by same provider but now patient is covered by some insurance. The provider will consider this patient as new or established on this visit?
    Any suggestions will be greatly appreciated.


  2. #2
    Phoenix, AZ
    Patient would still be established. This is not an insurance rule - its a CPT rule. The patient could have 10 different insurances but would still be established.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  3. #3
    Quote Originally Posted by Cyndi113 View Post
    Patient would still be established. This is not an insurance rule - its a CPT rule. The patient could have 10 different insurances but would still be established.
    Thanks Cyndi.

  4. Default
    Would the patient still be considered estabilished if the old practice is dissolved and a new one created.

    In other words - the practice is under the tax id of the hospital and the old tax id and any other payer numbers won't be used.

  5. #5
    If the patient was seen by that provider within the last 3 years, he is considered established.
    adrianne, cpc

  6. #6
    San Antonio, Tx
    The "key" in determining NP vs Est Pt is NOT the tax ID but the physician. If the pt has been seen by the "Physician"in the past 3 yrs, then they are Established pts.
    Ray Galvez CPC

  7. Default
    How about if there were two physicians, same specialty, in the Same building, sharing call with eachother, sharing the same chart, but billing as SEPARATE practices and under different TIN's.

    Are their patients "established" to eachother?

    I work for a hospital based clinic that just hired on these two physicians from private practice. They are now both employeed physicians in the same practice with the same TIN.

    They think that because before they were billing w/ different TIN and owned their own practices they could consider eachother's patients as "new" the first time they were seen.
    Rachell Lindley, CPC
    Multispecialty Clinic Coding
    Internal Medicine
    General Surgery
    Family Medicine

  8. Default Same Tax ID, group and speciality, different location
    I have the same question - 2 physicians, separate locations, same tax ID, same group, same specialty. We billed as a new patient but patient was seen by another FP in the same GROUP not the same PRACTICE and the claim denied stating they are not new because they have seen another physician within the group within the last 3 years.....any comments?

  9. #9
    North Carolina
    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 ) from the physician or physician group practice (same physician specialty) within the previous 3 years.

    Your patient would be deemed established by CPT and Medicare guidelines...
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

  10. Default Emergency room - Clinic
    Critical Access Hospital with a provider based Rural Health Clinic. If patient was seen in the ER and then seen two weeks later in our RHC does this still qualify as an established patient even though they were seen in the hospital and then the clinic? Patient has never been seen in the RHC.

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