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Is it a "new patient" or "established patient"?

  1. Default Is it a "new patient" or "established patient"?
    Medical Coding Books
    Good morning,

    I'm finding the description of new patient vs established patient as it related to this example a little confusing. Hope someone can give me their opinion.

    If I see a provider at an urgent care facitlity continually. The provider is acting as my PCP. The provider decides to leave the urgent care and join a practice three weeks after my last visit at the urgent care center. Am I now a "new patient" at your new office or am I still an "established patient".

    The description says, " A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within three years."

    Does it matter what practice I belong to? I could keep moving practices and charging existing patients "new patient fees"? Is this ethical or allowed according to CPT guideline?

    Thanks in advance for your help and advice?
    Mary Beth

  2. #2
    Location
    Evansville Indiana
    Posts
    451
    Default New vs established
    These patients would be established no matter how many times the MD changes practices, as long as the MD has seen them face to face in the last three years.
    LeeAnn

  3. Default
    Thank you

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Maybe this will help
    Scenario 1
    Patient Jones sees Dr A at the Red Clinic for several visits over the last year.
    Dr A leaves Red Clinic to go to Green Practice.
    Patient Jones now sees Dr A at the Green Practice.
    Patient Jones is established with Dr A becuase he has received face-to-face services from Dr A within the last 3 years.

    Scenario 2
    Patient Smith has never seen Dr A before and has never been to the Red Clinic.
    Patient Smith regularly sees Dr B at the Green Practice.
    Dr A leaves Red Clinic to go to Green Practice.
    Patient Smith comes to the Green Practice when Dr B is out of office, and sees Dr A instead.
    Patient Smith is established, because he has received face-to-face services from another physician in the same practice and the same specialty within the past 3 years (Dr B)

    I can't think of a more clear way to explain this.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. Default
    Thank you!

    You cannot believe how this provider is still arguing about this. Now they are saying it's ok to bill as a new patient because:

    They are not credntialed yet with the ins co., so they are billing under a different MD in the practice who co-signs the note. Your a new patient to him! Are you kidding me? He never saw the patient? Since when do we bill "incident to" for MD's? Why does one MD co-sign another note when they are not a resident? Bizarre, and they said they cannot correct the claim with the ins co because it has already been "adjudicated". Huh? You mean it's ok to incorrectly bill and they have no responsibility to correct their error? Isn't this coding and billing 101?

    So frustrating! OFcourse, the patient has a HUGE deductible and they want them to pay the new patient bill.

    Mary Beth

  6. #6
    Location
    Evansville Indiana
    Posts
    451
    Default New vs established
    As far as I know, one MD cannot bill under another MD's NPI.

  7. #7
    Location
    North Carolina
    Posts
    3,126
    Default
    Medicare absolutley does not...

    Knowing misuse of provider identification numbers, which results in improper billing; 16

    16= An example of this is when the practice bills for a service performed by Dr. B, who has not yet been issued a Medicare provider number, using Dr. A's Medicare provider number. Physician practices need to bill using the correct Medicare provider number, even if that means delaying billing until the physician receives his/her provider number.

    http://oig.hhs.gov/authorities/docs/physician.pdf

  8. Default
    Quote Originally Posted by mb1camacho View Post
    Thank you!

    You cannot believe how this provider is still arguing about this. Now they are saying it's ok to bill as a new patient because:

    They are not credntialed yet with the ins co., so they are billing under a different MD in the practice who co-signs the note. Your a new patient to him! Are you kidding me? He never saw the patient? Since when do we bill "incident to" for MD's? Why does one MD co-sign another note when they are not a resident? Bizarre, and they said they cannot correct the claim with the ins co because it has already been "adjudicated". Huh? You mean it's ok to incorrectly bill and they have no responsibility to correct their error? Isn't this coding and billing 101?

    So frustrating! OFcourse, the patient has a HUGE deductible and they want them to pay the new patient bill.

    Mary Beth
    I have five letters for you that should scare the crap out of them, but obviously they are above that... F R A U D

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