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New Patient Billing

  1. #1
    Location
    Richardson
    Posts
    19
    Default New Patient Billing
    Medical Coding Books
    My office has some conflicting view points on how to bill a NEW PATIENT office visit.

    I am part of a group or orthopaedic specialists. I have 2 hand specialists, 2 pain management specialists, also 2 foot specialists, among others.

    Can hand specilaist Dr. 1 bill out for a NEW PATIENT office visit if a Dr. in the same practice under the SAME TAX ID just billed out for a NEW PATIENT, let's say, 2 days prior?

    We have one party that is under the assumption that because DR. 1 is a hand specialist, that he can bill out a new patient consult. Then we have another party that thinks that unless it is PAIN MANAGEMENT, you can not bill out for a new patient consult.

    Hope this makes sense.

  2. #2
    Default
    Quote Originally Posted by meganbruce View Post
    My office has some conflicting view points on how to bill a NEW PATIENT office visit.

    I am part of a group or orthopaedic specialists. I have 2 hand specialists, 2 pain management specialists, also 2 foot specialists, among others.

    Can hand specilaist Dr. 1 bill out for a NEW PATIENT office visit if a Dr. in the same practice under the SAME TAX ID just billed out for a NEW PATIENT, let's say, 2 days prior?

    We have one party that is under the assumption that because DR. 1 is a hand specialist, that he can bill out a new patient consult. Then we have another party that thinks that unless it is PAIN MANAGEMENT, you can not bill out for a new patient consult.

    Hope this makes sense.
    I'm not sure who wins, but if Dr. 1 and Dr. 2 aren't the same specialty (i.e., the same provider type on their claim forms - 8=Family practice, 11=internal medicine, etc.), then they both saw a 'new' patient. They have to have the same tax ID and provider type for the patient to become established. Hope that helps

  3. #3
    Default CMS Specialty Codes
    CMS has a list of Specialty Codes and they recognize Hand Surgery as a distinct specialty; commercial payers may or may not. Also, it depend's on how the provider is credentialed with Medicare and the individual payers. In our practice, established patients can be coded as "new" when first seen by our hand surgeon or the physical med & rehab docs. I say "can" because it's not always that simple. Documentation requirements for a new patient E/M code are higher than for an established patient so you might want to look at the difference in reimbursement between, let's say, a 99203 and a 99214. And when you have to appeal and fight with a payer to prove it is a distinct specialty visit with an appropriate diagnosis, you may "spend" all the additional payment a new patient code would get!
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group
    melanie.zinser@ohiohealth.com

  4. #4
    Default Consult codes
    Also, I see you mention consult codes. My understanding is they aren't "new" OR "established" - if the provider has a distinct area of expertise and it truly meets consult criteria (not a transfer of care) any of the docs in a group could bill a consult, except to Medicare, of course.
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group
    melanie.zinser@ohiohealth.com

  5. #5
    Location
    Jackson, TN
    Posts
    77
    Default
    Hey can you give me some documentation that justifies this? we are getting denials whenever we do this.. (similar situation as above)

  6. #6
    Unhappy oops
    I looked through my documentation for our "spine" doc billing a consultation on an established "hip" patient, and everything is from CMS, who, of course, doesn't recognize consultation codes anymore! This is probably one of the reasons why. In theory, you could try to fight this with commercial payers, but probably end up wasting more time and money than it is worth.
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group
    melanie.zinser@ohiohealth.com

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