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Thread: New vs Establish

  1. #1
    Join Date
    Apr 2007
    New Orleans

    Default New vs Establish

    AAPC: Back to School
    If patient came in and received ear piercing and no OV charged patient paid for service in 2010. Then return for OV in 2011 is that a new patient or establish patient.


  2. #2
    Join Date
    Apr 2007


    He was seen within a year...technically he is a est. pt

  3. #3
    Join Date
    Apr 2007
    Lubbock, TX


    One of the new provisions of HITECH (I think), is that if a patient pays for a visit entirely out of pocket, they can choose not to allow the records for that date of service to be disclosed to an insurer, if they want. If they pay completely out of pocket, they can basically control whether or not an insurer knows that the encounter ever happened.

    That being said, you should make sure that the patient would be okay with you disclosing his self-paid procedure from 2010 to his insurance, to avoid any legal liability. (I doubt he'd care in this situation, but someone else, with a pre-existing condition, might.) You should consult with your compliance department on how to handle billing a patient's insurance who would not want a self-paid initial encounter disclosed.

    Technically, though, this is an established patient. If they received any service that is reportable with a CPT or HCPCS code within the past 3 years from your doctor (or another MD in the same practice w/the same specialty), then they're established.

  4. #4
    Join Date
    Apr 2007
    New Orleans


    Thanks ladies

    Our billing system scrubber was kicking it back to us because the patient was not charged a OV in 2010.

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