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Part B Insider (Multispecialty) Coding Alert

Reader Question: Established Patients Remain Established, Despite New Problems


- Published on Fri, Sep 16, 2011
Question: Our office saw a patient six months ago for a certain condition, and sent the patient back to his primary care provider for further treatment. The same patient was recently referred back to us for a different condition. Should we bill that patient as new, since he's coming back for a different reason? Answer: This patient should be considered "established" for many reasons. If your physician sees a patient any time within a 36-month period, that patient is considered established, regardless of the reasons for the visits. This is the AMA's "three-year rule." You should go by this rule even if another physician in your practice sees the patient, as long as it's within the 36 months. Location is not a factor either, in the event your practice has more than one location. Why: This rule applies as long as all the physicians in your group bill under the [...]


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