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New vs. Established for Radiology Physician

  1. Question New vs. Established for Radiology Physician
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    I work for a group of radiologists-- a few times a month one of our radiologists goes to a vascular clinic and sees patients face to face - normally as a consult to see if the are good candidates for procedures such as epidurals of venous ablation.

    Any who I have a denial:

    I billed 99202 (new pt) and I am being denied for "PAYMENT ADJUSTED BECAUSE NEW PATIENT QUALIFICATIONS WERE NOT MET".... now 2 years ago our office read an ultrasound done on this patient but this is the first time we saw the patient face to face or billed an OV in six years.

    Per the CPT book: Distinguishing between new & est. patients, professional services are those face to face services rendered by a physician and reports by a specific CPT code. A new patient is one who as not received any professional services from the physician (or one from same practice) with in the past 3 years.

    So my dilemma..... Is this a New Pt Ov b/c we have not seen the pt face to face in over 3 yrs? ...... or...... Is this an est. pt. bc we have billed a prof. component w/in the past 3 yrs?


    PLEASE ADVICE

  2. #2
    Default Re: New vs. Established for Radiology Physician
    You are correct about the 3 year rule for new vs established. As long as there is only 1 E/M from for the day within that same specialty. However you also have to meat the requirements for the new patient.

    So I would start by looking to be sure the HPI has 1-3 components met, exam has 1 pertantent to the problem and that the MDM is low or better. No PFSH is needed so if al are met. I would make an appeal and find out why it was denied.

  3. Default
    Thank you for your responce.I did call and the insurance did state it was because we had provided services to the patient w/in the past three years.

    I guess to simply my question is if our radiologist group as read an ultrasound done 2 yrs ago at a local hosp- but never had a face to face appt with the pt-- then an office visit is schedueld .... is the pt considered new or established?


    I was hoping to find some documention to help my case but I have been unable to find anything yet.

  4. #4
    Default
    Your answer will be found in your CPT book CPT Professional Edition 2011 page10:
    Coding Tip: Determination of patient status as new or established patient.
    Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

    That's only partial. So, see what your CPT has to say. If the patient hasn't been seen FACE-TO-FACE by your physician or anyone else in that practice of the same specialty, then it's a new patient. Reading the ultra sound previously would not qualify for face to face.

    anyone else?
    Last edited by Anna Weaver; 09-20-2011 at 06:19 AM. Reason: continuing
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  5. Default
    it says in the CPT

    Determination of patient status as new or established patient. Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s).............. pt has not been seen face to face


    "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years" ............. but we have provided professional services

    so... other then the def in the CPT (which is contradicting thou that is why I am questioning it) any know where I can find a better clearer def?

  6. #6
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    Default
    The CMS definition is more explicit even than the CPT book.
    "A Definition of New Patient for Selection of E/M Visit Code
    Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient."

    Other payers, however, have their own rules and while you can (and should) appeal - apparently this payer has decided any service makes the patient established.
    CPT Assistant August 2009 warns "Because definitinos of new and established patients may differ based upon individual third-party payer guidelines, it is important to familiarize yourself with the various reportint and reimbursement policies..."

  7. Default
    Thanks so much! That's what I was thinking it's reassuring to know that people have them same point of view since this is how I have been billing these for the past yr. The denial I received was the first one - and it concerned me.

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