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new vs established patient in new physician group practice

  1. Default new vs established patient in new physician group practice
    Exam Training Packages
    need comments concerning a patient who was previously seen by an endocrinologist in a previous group practice---physician has left that practice and joined a new group---is the patient a "new" patient to the new group practice (new ein#, new NPI for practice, etc) or established since patient had been seen by physician in the previous practice...Thank you!

  2. #2
    Location
    Salt Lake City
    Posts
    841
    Default
    hmm same NPI but different tax ID, I would assume a new pt would get denied based on the NPI but I am curious to see what other people think.
    Jenifer McPolin CPC, CPMA, RCC

  3. Default
    We just went through this. Although the patient is new to the group, the patient is not new to the physician. It would be an established patient.

  4. #4
    Default New vs Established
    I was just have ing this discussion today regarding my Med Oncs vs Rad Oncs. I am attaching the current definition from MLN.

    "A new patient is defined as an individual who has not received any professional
    services from the physician/non-physician practitioner (NPP) or another physician of the
    same specialty who belongs to the same group practice within the previous three years.
    (Same group is determined by Tax ID and NPI Organization number billed on claims)

    An established patient is an individual who has received professional services from
    the physician/NPP or another physician of the same specialty who belongs to the same
    group practice within the previous three years."
    Peggy McCormick, CPC
    Adventist Health Systems
    California Medical Group
    mccormpc@ah.org

  5. #5
    Default
    Quote Originally Posted by 1lisajoey View Post
    I was just have ing this discussion today regarding my Med Oncs vs Rad Oncs. I am attaching the current definition from MLN.

    "A new patient is defined as an individual who has not received any professional
    services from the physician/non-physician practitioner (NPP) or another physician of the
    same specialty who belongs to the same group practice within the previous three years.
    (Same group is determined by Tax ID and NPI Organization number billed on claims)

    An established patient is an individual who has received professional services from
    the physician/NPP or another physician of the same specialty who belongs to the same
    group practice within the previous three years."
    I agree, however, it is my understanding there is a new guideline that allows Speciality MDs to code as a new patient when being seen as a Specialist for treatment of new diagnosis. Are you familiar with this?

  6. #6
    Default
    I am also wondering the same thing, I was just in a seminar that says it is based on tax id and they are working to be able to drill down to taxonomy, however I am now in a different seminar and they are instructing that it is based on SUB specialty. We are currently getting denials from this but I cannot find the direction.....

    Does anyone have documentation?

    Thanks
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Established
    I'll try to make this simple.

    Dr A sees Patient X at Practice Green in February 2011
    Dr A leaves Practice Green for Practice Red in October 2011
    Dr A sees Patient X at Practice Red in February 2012

    Patient X is STILL an established patient because the physician has provided a face-to-face service to the patient in the last three years.

    If Dr A is not available and Dr B (who has the same specialty or subspecialty in Practice Red sees Patient X ... the patient will still be considered established, because Face to face services have been rendered by the physician (or another physician in the same practice, same sub/specialty) in the last 3 years.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  8. #8
    Location
    Milwaukee WI
    Posts
    4,466
    Default Ask yourself these questions
    Q1 - Has this patient been seen by ANYONE in this practice in the last three years?

    NO? - it's a new patient

    YES? next question

    Q1 - Has this patient been seen by THIS physician or any other physician in THIS practice with the same specialty / subspecialty (as appropriate).

    NO? It's a new patient
    YES? Established.

    Location makes no difference, tax ID makes no difference.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  9. #9
    Default
    That is opposite of what I am seeing in denials as well as what I was told in the seminar last wednesday. My circumstance is I have one practice - 4 cardiologist - 2 CVT - 2 EP doc's. This is all ONE practice under ONE tax-ID. We are seeing denials not only for new vs established patients but with patients in a global period. The very knowledgable gentleman that spoke at last wednesday's seminar said that this was still based on group (tax ID) and later this year the guidelines would change to go all the way down to taxonomy because Medicare was looking at bringing consultations back.

    Any thoughts?
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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