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Thread: New vs est pt /3 year rule-NOT MEDICARE

  1. #1

    Default New vs est pt /3 year rule-NOT MEDICARE

    AAPC: Back to School
    We have a question regarding the new patient vs. established/three year rule for Non-Medicare Patients. It is the same question below that we found on the NGS Medicare website from a teleconference, they had in 2010 and posted it on 3/3/2010 and they gave their reply below.

    However, does this apply to non-medicare patients


    New vs. Established/Three Year Rule

    We have new physicians joining our practice from other practices. For example, we have a new orthopedist. He saw a particular patient in his previous practice under a different tax ID, within the three year limit. When he sees the patient for the first time within our practice, can we bill it as a new patient?

    Medicare's Answer: The new patient rule is based on the physician who renders the service. If this physician has seen the patient within the past three years, even in a different practice, this does not represent a new patient visit.

    Remember I would like to know if this is only a Medicare Rule?

    Thank you Toni P

  2. #2
    Join Date
    Apr 2007
    Evansville Indiana

    Default New vs. established

    This is a CPT guideline, so it should be followed by all payers. You can find the guideline in the CPT book just before the E&M codes under E&M Services Guidelines, then under New and Established Patient. They also provide a decision tree for new vs established.
    So to answer your question this would be an established patient whether they are Medicare or not.

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