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3 Year Rule When Billing E&M Visits

  1. #11
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Medical Coding Books
    Quote Originally Posted by juliejenkins2005 View Post
    Sorry I do not agree. That new doctor is coming into a new practice and billing under a new tax ID number, I feel that it could be billed as a new patient. I don't feel that he shoud loose out on that new patient visit. That is just thought.
    A patient is conisdered established if they were seen within a 3 year period by any physician of the same specialty in the group. If your old doctor in his new practice has seen the patient within the three years and his new doctor in his practice sees the patient then it would still be established based on same specialty same practice.

    Let me add this: Same situation, what happens when the "old doctor" retires and leaves the practice and I still have these patients transferring over from the old practice. We are still in that "3 year period". How would you explain not billing a new patient vist for my new doctor and NP in this new practice?
    If the old doctor retires and leaves the practice, the patients are still established to the practice and the doctor seeing the patient is still part of that practice - then it would still be established, not new.
    Jodi Dibble, CPC

  2. #12
    Default
    It is my understanding that the NPI number is what the insurance tracks by not the tax id number. We have had phyisicans move into our clinic from their own and some of our physicians did try to bill as new and were denied because the doctor that joined NPI's revealed him with the practice now.
    I could be wrong be we had to change several claims to established patients.
    Debbie Potts England
    Lyles, TN 37098

  3. #13
    Location
    Milwaukee WI
    Posts
    4,466
    Default Could you be more clear?
    If I understand the scenario correctly, these patients are ESTABLISHED.

    To make it easy, let's give these providers names.
    Doctor OLD left his old practice and joined your NEW PRACTICE. Any patients from his old practice who follow Dr OLD to the NEW PRACTICE are established if he provided any face-to-face service within the last 3 years.

    Doctor New and Nurse NP have now joined the NEW PRACTICE . The rule states that a patient is considered established if they have received face-to-face services from that provider or any other provider of the same specialty and same practice within the last three years. So if Dr New or Nurse NP sees one of Dr Old's patients, that patient is considered established ... because the patient has received face-to-face service by another provider of the same specialty and same practice within the last three years.

    If one of Dr Old's patients who was last seen by him 5 years ago, happens to come back to him or to Dr New now ... that patient is a NEW patient (becuase it's been more than 3 years since the last face-to-face service).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #14
    Default
    It is my understanding that when billing ESTABLISHED patient, the patient is an established patient if he has been seen by a provider of same speciality within the last three year. Tax-id also plays a role in determining this. If we are billing under the same tax-id, then patient is always an established within the three year period. If we are billing under a new tax-id, we can bill the patient as a NEW patient. However, this rule does not apply to Medicare patients - Medicare follows NPI # - if the patient has been seen by a provider within the three year period - the patient is always an ESTABLISHED patient no matter what his tax-id is because the NPI# is the same. Thus you need to check with specific payor you are billing for.

  5. #15
    Location
    Milwaukee WI
    Posts
    4,466
    Default Tax ID makes NO difference
    Quote Originally Posted by saagar View Post
    It is my understanding that when billing ESTABLISHED patient, the patient is an established patient if he has been seen by a provider of same speciality within the last three year. Tax-id also plays a role in determining this. If we are billing under the same tax-id, then patient is always an established within the three year period. If we are billing under a new tax-id, we can bill the patient as a NEW patient. However, this rule does not apply to Medicare patients - Medicare follows NPI # - if the patient has been seen by a provider within the three year period - the patient is always an ESTABLISHED patient no matter what his tax-id is because the NPI# is the same. Thus you need to check with specific payor you are billing for.
    The NEW vs established patient rule is PROVIDER specific. Tax ID makes no difference. Please get the above quote out of your head. Whether it's Medicare or any other carrier ... CPT is very specific about this.

    If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED. Tax ID makes no difference.

    F Tessa Bartels, CPC, CEMC

  6. #16
    Default With a twist!
    The NEW vs established patient rule is PROVIDER specific. Tax ID makes no difference. Please get the above quote out of your head. Whether it's Medicare or any other carrier ... CPT is very specific about this.

    If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED. Tax ID makes no difference.

    F Tessa Bartels, CPC, CEMC


    Hey Tessa:

    Just want to pick your brain about this because mine is spent at the moment.... I've run into a situation and I'm literally on the fence about it.

    I work for a Medical Group so we have several FP, IM practices using the same tax id#. We have a patient who transferred their records from one FP under our umbrella to another FM under our umbrella. The new office wants to bill a new patient visit for this patient today.

    Do the same rules apply here that you mention in your above response now. My personal thought is "no, the new FP under the same umbrella can't bill a New patient visit" but I'm on the fence.

    Or can they bill a new patient visit because it's a physician who hasn't seen this patient and it's not the same practice BUT it's under the same "umbrella" ( tax id#)

    I'm going to check my mac to see if they have any info on this as well.

    Thanks
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  7. #17
    Default I got it...
    Just found my answer in the CPT book....

    " A new patient is one who has not received any professional services from teh physician or antoher physician of the exact same speciality and subspecialty who belongs to the sme group practice, withint eh past three years".

    So this patient that I have would be considered a new patient to this different group practice.

    It's nice when you can answer your own question ( after you've asked it) LOL
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  8. #18
    Location
    Kansas City, MO
    Posts
    434
    Default
    Roxanne, per Medicare, same tax id & same specialty = same person. We have several clinics under the same tax id "umbrella". We do NOT charge a new patient when the patient switches clinics. I asked this very question to our MAC.

    http://www.wpsmedicare.com/j5macpart...services.shtml
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  9. #19
    Location
    Kansas City, MO
    Posts
    434
    Default
    Quote Originally Posted by FTessaBartels View Post
    The NEW vs established patient rule is PROVIDER specific. Tax ID makes no difference. Please get the above quote out of your head. Whether it's Medicare or any other carrier ... CPT is very specific about this.

    If the patient has been seen by this provider or any other provider with the same specialty, same practice within the last three years, the patient is ESTABLISHED. Tax ID makes no difference.

    F Tessa Bartels, CPC, CEMC
    Comepletely agree. Bypassing the claims system due to different tax ID's, abd getting your claim paid , does not make it right.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  10. #20
    Default
    I believe that the "3 year rule" follows the patient and not the provider, if that was the case and the provider switched practices often and the patient followed them, they would be charged new pt visits more than allowed, i believe that it reads that the "patient" has not been seen in 3yrs by a provider in that specialty or of the same specialty...

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