When billing insurance for evaluation and management (E&M) services, you have to document if the patient is new or
established, depending on whether you’ve had previous encounters with the
patient — and depending on which type of plan is paying the bill.
Current Procedural Terminology
(CPT) defines a new patient as
one who has not received any professional services from the physician or
another physician of the exact same
specialty and subspecialty in the
same group practice, within the past three years. CPT recognizes specialties
and subspecialties listed in the National Uniform Claim Committee’s (NUCC’s) Health Care Provider Taxonomy Code Set.
The Centers for Medicare &
Medicaid Services (CMS) definition is a little different. It defines a new patient as one who has not received any professional services from the
physician/nonphysician practitioner or another physician of the same specialty who belongs to the same
group practice within the previous three years.
CMS determines the same specialty
by the physician’s primary
specialty enrollment in Medicare. The Medicare Claims Processing Manual, Chapter 26, lists Medicare specialties.
CMS also
provides a Medicare-specialty-code-to-health-care-provider-taxonomy-code
crosswalk.
For example, the crosswalk shows that Medicare specialty code 34, Urology,
encompasses all three subspecialties listed in the NUCC taxonomy code set:
urology, pediatric urology, and female pelvic medicine and reconstructive
surgery. So, if a pelvic medicine specialist provided an E&M service to a
patient who had seen a urologist in the same practice within the past three
years, the pelvic medicine specialist could bill a commercial plan that follows
the CPT definition under a “new patient” E&M code. Under the Medicare
definition, this patient would be billed as an “established” patient.
If you have questions about
billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800)
880-7955. Need extra help with coding and documentation? TMA Practice Consulting
can perform custom training, check-ups, and reviews. Call a consultant for more
information at (800) 523-8776 or email practice.consulting[at]texmed[dot]org.
Also, visit TMA’s Billing and Coding page for additional resources.
Published July 12, 2016
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