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New patient cpt codes within group practice

  1. #1
    Cool New patient cpt codes within group practice
    Medical Coding Books
    Hello- I've been presented with a question & putting this out there to get anyone's opinion.

    Scenerio - same group/tax id#. All dates of service are within 3 year time frame.

    Patient sees dermatologist A & is referred within practice to plastic surgeon B for treatment. A consultation code cannot be billed to Medicare for the plastic surgeon any longer. Can a new patient E/M be billed since he is not like speciality?

    Next - this patient returns for a NEW condition/dx unrelated to the last visit and is seen by dermatologist again. This is billed as established E/M. He is referred to same plastic surgeon again for this NEW condition. Can a new patient E/M be billed since consult cpt is not longer allowable by Medicare?

    Here is the definition from CMS for new vs subsequent but it doesnt specify different diagnosis.

    In an office setting, the physician will choose either a new or a subsequent patient visit based on whether the physician provided any face-to-face services to that patient within the previous three years. A patient is new if there has been no face-to-face service provided in the previous three years by the same physician or a member of the same group with the same specialty. A patient is established when there has been face-to-face contact within the previous three years.

    thanks for your input and if you have any resources that may provide addtional info, please post

  2. #2
    Milwaukee WI
    Default New vs Established Patient
    Makes NO difference whether the diagnosis is new or established.

    A ESTABLISHED patient is one who has received any face-to-face service by the provider, OR another provider of the SAME specialty and SAME practice within the last three years.

    Plastic surgery and dermatology are two distinct specialties.

    Now to the specifics you pose.
    You wrote: Patient sees dermatologist A & is referred within practice to plastic surgeon B for treatment. (emphasis added by FTB) If patient is sent for treatment, then treatment is probably all you can code. IF there is a significant, separately identifiable E/M service provided on that first visit to the plastic surgeon, the patient is a NEW patient (as long as the patient hasn't seen that plastic surgeon, or any other plastic surgeon in the same group practice within the past three years.)

    The next time the patient shows up in either dermatologist or plastic surgeon office, WITHIN 3 YEARS of the first visit ... the patient is established. Whether you can code an E/M and a procedure depends on the documentation (as always).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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