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Hospital Stay Then New pt E/M

  1. #1
    Default Hospital Stay Then New pt E/M
    Medical Coding Books
    Hi. Could someone please clarify. The baby is seen as babyboy or babygirl in the hosptial for h&p and discharge after deliveryl by the peds doctor under moms ID. Is it considered a new pt physical once the baby is seen in the office by the same ped physician for the babys 2 week check up? I know what the guidelines state in CPT, but I was just wondering how other offices are coding this scenerio. Thanks

  2. #2
    When the baby is seen in the hospital by the doctor and then the baby comes into the office this E/M would be established. The doctor had a face to face with the patient so the baby would not be a new patient.

  3. #3
    Is this scenario something you are coding daily and is this the way your office is coding? Are n/p physicals only for patients who have not been seen in the hospital by the physician? The baby has a different insurance and now using his/hers name other than the mother. Does anybody else have any othe input or have any references I could show the doctor? Thanks.

  4. #4
    Default newborn physicals
    I don't code the inpatient part of the newborn, but code for a 2 day newborn physical and 2 week physical and so on in the Clinic.

    I agree with the reply above. If the baby was seen by the same provider in the hospital as for the 2 day or 2 week follow-up, it would be considered an established E&M 99391.

    The only time I code the encounter as New Patient Encounter if the providers are not the same.

    Hope this helps,
    The Oracle

  5. #5
    thanks for the tips, it helps, but I'm hoping someone who is coding this daily would respond. the insurances are different. the mom has federal and the baby has state. the provider advised that the insurance would deny the follow up visit because it was never previously billed. since we are applying for the insurance for the baby in our office and in order for the pt to be eligible, the code would need to be billed as n/p. I know it sounds weird, but i have never seen the denial and that is why i asked this question. the office has applied for the state insurance for the newborns using their name for 10 years and has billed a n/p physical even if the peds doctor saw the baby to discharge out of the hosptial under the moms insurance as babygirl/babyboy. wish i knew of a website to contact because if this is true this state funded insurance totally contradicts CPT. would still like any help because i would like to cover myself.

  6. #6
    If you are submitting CPT codes, you must follow CPT guidelines, not what insurance companies dictate.
    Check your CPT manual in the E/M guideline section. Most books have a decision tree for new vs established patients. The visits are based on professional services, not place of service.
    In the case you gave, the patient would be established.

  7. #7
    Thanks for tips and have already checked it out. Still just wondering if the state funded insurance would deny a follow up visit instead of the n/p. we are the office that is applying for the insurance as soon as the patient/newborn walks into the office and is seen within 5 minutes. it was stated to me by the office who has billed this for over 10 years, that in order for any of the services to processed, the n/p visit would need to be billed initially. i may need to check the website policy. maybe california medi-cal, medi-cal hmo, etc have their own rules that overlook cpt guidelines???? But i do appreciate all the input

  8. #8
    Unless the payor specifically says you MUST bill a new patient visit, then I agree with all the previous responses.

    The type of insurance or changing of insurance has nothing do with whether a pt is a new pt or established patient.

    If the provider performed a previous face-to-face service, the patient is now established.

    Patients change insurance all the time. I suppose you could get away with billing a new patient visit whenever a patient changes insurance, because this payor would have no record of previous encounters.... but just because you can get away with it, does not make it right. Submitting a false claim is fraud.

    Good luck!


  9. #9
    thank you for all of your support. i have recently learned that i am to enter the CPT code in the system as a new patient and the CPT is never sent to the insurance. the insurance we apply for is run through the state called CHDP. they have their own software and the data i enter is for internal use only. once i have entered the CPT in the billing software, it then gets entered into the CHDP software without CPT codes. it uses the description and all the data regarding the child is entered so the state can track it. once CHDP pays, the payment is posted to the billing software, so when i run the aging it shows the claim paid or unpaid. i am so glad that everyone on the forum supported me because i did not want to commit any fraud, and i knew the provider is a very good doctor an he doesn't commit fraud. so i knew i needed to just keep trying to find the answer. thanks so much

    Leilani, CPC

  10. #10
    Portland Metro
    Why would the insurance company deny a return visit just because you haven't billed that company before? People change insurance all the time. Just because a patient is new to the insurance company doesn't mean they are a new patient to the provider. This is especially true of newborns, and the insurance company knows this. Actually, you are more likely to get a denial if you bill this as a new patient.
    FYI I specialize in Pediatric inpatient E/M, and I also process denials.

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