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Hospital coding & office

  1. #11
    Red face I get it...I was wrong.
    Medical Coding Books
    Quote Originally Posted by btadlock1 View Post
    It matters when you're talking about the patient seeing multiple physicians in a group practice. If the patient is seen by a provider, then seen by a second provider of the same specialty in the same group practice (as identified by either their billing NPI or Tax ID, which should be the same for all providers in the same group practice), the patient is considered established for the second provider, regardless of whether or not they've ever seen the patient before. However, both doctors could be in the same group, and if they're different specialties, both could see the patient as "new", even at the same location.

    Group physicians don't necessarily have to be located in the same facility, so it is possible for a patient to see one physician in a group practice in the hospital, and see a different provider of the same specialty, who belongs to the same group, at a different location (eg, a clinic). The New/Established patient criteria for group physcians, isn't based off of location, it's based off of who is in the group, and what specialty they are. If the question is regarding the same physician seeing the patient at 2 different locations, then the visit is established the second time, regardless of group affiliation/NPI/Tax ID. I was incorrect in saying that it might make a difference if the physician is associated with more than one practice - I apologize if that caused any confusion.

    These articles cover most scenarios for this question:
    http://www.supercoder.com/articles/a...reimbursement/
    http://www.aafp.org/fpm/2003/0900/p33.html
    I've acknowledged that I was wrong, but evidently, I need to say it again. I was wrong when I said that it might make a difference if the physician is associated with more than one practice, and I am truly sorry if it caused any confusion. It doesn't make a difference if the doctor is billing under the same information (individual, group, or otherwise) from the last visit or not; if they have personally provided professional services to the patient in the past 3 years, the visit is established.

    I would like to point out, though, that Medicare's requirements are slightly different than CPT's. It's probably not applicable to this particular situation, but as Pam mentioned, a lot of people read these forums to answer their own questions. For the benefit of those readers, keep in mind that the professional service must be a face-to-face service, for it to change the patient's designation from 'new' to 'established', if they're a Medicare patient. See the AAFP's article above...

    "A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate."

  2. #12
    Default
    Quote Originally Posted by btadlock1 View Post
    I've acknowledged that I was wrong, but evidently, I need to say it again. I was wrong when I said that it might make a difference if the physician is associated with more than one practice, and I am truly sorry if it caused any confusion. It doesn't make a difference if the doctor is billing under the same information (individual, group, or otherwise) from the last visit or not; if they have personally provided professional services to the patient in the past 3 years, the visit is established.

    I would like to point out, though, that Medicare's requirements are slightly different than CPT's. It's probably not applicable to this particular situation, but as Pam mentioned, a lot of people read these forums to answer their own questions. For the benefit of those readers, keep in mind that the professional service must be a face-to-face service, for it to change the patient's designation from 'new' to 'established', if they're a Medicare patient. See the AAFP's article above...

    "A slightly different approach may be taken when Medicare patients are involved. Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters. Therefore, if you see a Medicare patient whom you have seen within the last three years, you must report the service using an established patient code. On the other hand, if a lab interpretation is billed but no face-to-face encounter took place, the new patient designation might be appropriate."
    I was not trying to prove you are wrong I was just trying to clarify the info for myself and all others. I dont want you to think you were wrong, we were debating to get the right answer and we got it (and a lot of extra usefull information). thanks for all your info, It was a pleasure "arguing" with you

  3. #13
    Default
    Quote Originally Posted by arme2783 View Post
    I was not trying to prove you are wrong. I was just trying to clarify the info for myself and all others. I dont want you to think you were wrong, we were debating to get the right answer and we got it (and a lot of extra usefull information). thanks for all your info, It was a pleasure "arguing" with you
    No worries - I was wrong! I'm glad that I was corrected on it, because I'd hate to give anyone bad information. It took me a couple of posts to realize I had been mistaken (actually, your post was the one that made go back and re-read what I'd said), but I'll be the first to admit when I make a mistake. It just seemed like maybe it wasn't clear that I had corrected myself to everyone (I was probably just being too sensitive).

    I totally understand your desire to debate - read a few of the threads I've posted in, and you'll see that I'm the exact same way. I don't (always) argue because I think I'm right; usually, I'm not sure if I'm right or wrong, and I'm just trying to pinpoint where I've got a flaw in my logic. The easiest way for me to do that, is to explain all of my logic, step-by-step, and that's perceived as 'arguing' to most people. It doesn't bother me to be wrong every once in a while...
    It's a learning opportunity - you learn a lot more from your mistakes, than from your successes; I can promise you that I won't be mistaken on this issue again.

  4. #14
    Default
    Quote Originally Posted by btadlock1 View Post
    No worries - I was wrong! I'm glad that I was corrected on it, because I'd hate to give anyone bad information. It took me a couple of posts to realize I had been mistaken (actually, your post was the one that made go back and re-read what I'd said), but I'll be the first to admit when I make a mistake. It just seemed like maybe it wasn't clear that I had corrected myself to everyone (I was probably just being too sensitive).

    I totally understand your desire to debate - read a few of the threads I've posted in, and you'll see that I'm the exact same way. I don't (always) argue because I think I'm right; usually, I'm not sure if I'm right or wrong, and I'm just trying to pinpoint where I've got a flaw in my logic. The easiest way for me to do that, is to explain all of my logic, step-by-step, and that's perceived as 'arguing' to most people. It doesn't bother me to be wrong every once in a while...
    It's a learning opportunity - you learn a lot more from your mistakes, than from your successes; I can promise you that I won't be mistaken on this issue again.
    Im glad you did not get mad. To me, ladies are always right even if they are wrong so I hope I did not hurt your fillings

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