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Hospital coding & office

  1. Default Hospital coding & office
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    If a dr saw a patient in the hospital but the but patient comes into the office as a new patient can we code 99204?

  2. #2
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    Quote Originally Posted by Jashani1 View Post
    If a dr saw a patient in the hospital but the but patient comes into the office as a new patient can we code 99204?
    If the doctor provided professional services to the patient (eg, did something that has a CPT code), within the past 3 years, then technically, the patient's established, even if they've never set foot in your clinic. It gets a little tricky when you consider that some providers are employed by a hospital and have their own separate private practice, and use 2 different tax ID's - in that situation, you may be able to bill a new patient charge, but otherwise, I'd go with an established code.

  3. Default
    It was an 99222 Initial hospital care. Then he came into the office for a visit about a week later.

  4. #4
    Location
    Milwaukee WI
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    Default Established
    The different tax ID is immaterial. The physician has one NPI number and that will govern making this patient an established patient when s/he eventually comes to the office.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Location
    Dover Seacoast New Hampshire
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    1,971
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    That's correct, Tessa. The provider's/facilities' TIN has nothing to do with new/established patient status. This is a common misconception.

    If the patient was seen at the hospital by your provider, and again at the office, at an outpatient clinic, or at a Wal-Mart clinic, it's still an established patient TO YOUR PROVIDER. Even if he moves to another practice location and brings that patient with him...it's an established visit.

    That's why New Patient issues are on the OIG radar all the time!
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  6. #6
    Default Just wanted to add...
    Quote Originally Posted by FTessaBartels View Post
    The different tax ID is immaterial. The physician has one NPI number and that will govern making this patient an established patient when s/he eventually comes to the office.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Group physicians have 2 NPI's - an individual (rendering) and a group (billing). The NPI that governs new versus established encounters is the billing NPI (the one that goes in box 33a on the CMS-1500). I usually just say Tax ID, because that is also standard across the group.

  7. #7
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    Quote Originally Posted by btadlock1 View Post
    Group physicians have 2 NPI's - an individual (rendering) and a group (billing). The NPI that governs new versus established encounters is the billing NPI (the one that goes in box 33a on the CMS-1500). I usually just say Tax ID, because that is also standard across the group.
    I would not agree with you.
    If the patient has received a face-to-face professional medical service from the physician within the past three years and that encounter was reported by means of one or more CPT codes, then the patient would be considered an established patient.

    Now, whats the difference where the Dr worked and what billing(group) NPI or tax ID the services was billed with? the service still was provided by the same Dr. Otherwise, the Dr would change the practice and see all his/her established patients as "new" since the billing NPI would be different.

  8. #8
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    Quote Originally Posted by arme2783 View Post
    I would not agree with you.
    If the patient has received a face-to-face professional medical service from the physician within the past three years and that encounter was reported by means of one or more CPT codes, then the patient would be considered an established patient.

    Now, whats the difference where the Dr worked and what billing(group) NPI or tax ID the services was billed with? the service still was provided by the same Dr. Otherwise, the Dr would change the practice and see all his/her established patients as "new" since the billing NPI would be different.
    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 saem 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

  9. #9
    Location
    Dover Seacoast New Hampshire
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    The original question had to do with a single provider...not a group practice, and as such, the TIN (or NPI for that matter) play no part in the new/established patient question. Not all providers use the same NPI for the same TIN, for example, we have providers who work for our physician corporation (one TIN) and also work for their private practice (different TIN). The new/established patient rules for them do not change based on the different practice settings that they work in. So to use TIN as a qualifier for a single physician is misleading.

    I do agree that the practice/specialty considerations play a part when patients see other providers in the same group. But again, the original post had to do with a single physician, and the comment about separate TINs for the same doctor leading to possibly billing a new patient visit is incorrect. I just wanted to clarify, because this board can confuse new coders who just want the right answer!
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  10. #10
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    Quote Originally Posted by Jashani1 View Post
    If a dr saw a patient in the hospital but the but patient comes into the office as a new patient can we code 99204?
    this was the original question. the answer is "NO". the patient is established. I dont know why btadlock1 brings up all this different TIN or NPI or different location issues here. I think it is a simple question requiring simple answer. No need to bring up different specialty/group or TIN/NPI issues.

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