New Patient Visit: Three Years Is a Key

Centers for Medicare & Medicaid Services (CMS)  recovery auditors have identified claims with “new patient” evaluation and management (E&M) services as having improper payments — because the new patient services have been billed for the same patient two or more times within three years by the same physician or physician group.

As a result of this finding, CMS will alter its common working file to prompt CMS contractors to validate that they are not paying two new-patient CPT codes within a three-year period (see MLN Matters No. MM8165 [PDF])

According to the Medicare Claims Processing Manual, (Chapter 12, Section 30.6.7) a new patient  is one who has not received any professional services, i.e., E&M service or other face-to-face service such as a surgical procedure, from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three-year period, e.g., a lab interpretation, 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.

The CMS three-year period is consistent with CPT guidelines. Many CPT books have a decision tree to help physicians determine a new versus established patient.

 From the 2013 CPT Guidelines:

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians … who may report evaluation and management services 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/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician/qualified health care professional or another physician … of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

In the instance where a physician … is on call for or covering for another physician … , the patient’s encounter will be classified as it would have been by the physician … who is not available. When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.

For more information, see:

If you need help with coding in your practice, turn to TMA Practice Consulting. TMA’s certified professional coders and auditors can train you and your staff, or perform an in-depth review or a check-up of your coding practices. To learn more about this service, contact TMA Practice Consulting at (800) 523-8776 or practice.consulting@texmed.org

Published May 21, 2013 


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