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New patient vs. preventive

Charlene Posted Wed 18th of December, 2019 17:28:58 PM
Our practice recently acquired an Urgent & Primary Care office, and this is a new specialty for us as we are a group of surgeons. The established PCP at the urgent/primary care office retired after a month with our group. The pre-existing PCP’s distant established patients are returning to the urgent/primary office (staffed by new providers) for medication refills WITHOUT CHIEF COMPLAINT. These are new E&M patients to our primary care providers and the new practice. The patients are being seen to remedy the need at hand and then scheduled for a later a visit to “establish care”. At the “establish care” visit a comprehensive history and exam and usually moderate decision making are documented. Multiple screening tests are usually ordered at this time. Should both services be done at the same time? Or the new patient E&M at 1st visit then followed by preventative visit (99395-99397)?
SuperCoder Answered Thu 19th of December, 2019 06:19:57 AM

Hi Charlene,

 

Thanks for your question.

 

As per CMS, an established patient is an individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years.

 

Now since this is a separate specialty, and different physician is evaluating the patient, it is appropriate to report services as new patient, but the documentation should contain the required key components to justify the CPT code.

 

If the only reason the patient comes in is to pick up a prescription and the provider does not see the patient for a documented E/M service, you cannot bill an E/M code.

 

Medication refills without medically necessary evaluation and management service are not separately reportable.

 

Ordering tests/screening/diagnostic service is a part of the evaluation and management service based on which E/M level of service is determined.

 

Please feel free to write if you have any question.

 

Thanks.

 

Charlene Posted Thu 19th of December, 2019 15:49:23 PM
At the first visit the provider is treating & documenting the immediate problem, and having the patient return to "establish care". I am not familiar with primary care. What does "establish care" mean? Wasn't the patient established with the provider at the first visit?
SuperCoder Answered Fri 20th of December, 2019 03:00:31 AM

The first visit may be billed where provider is treating the patient.

 

Establishing patient care is development of a relationship between the doctor and the patient. It is very important for people and their family to ensure their health and wellness.  It becomes easier to coordinate all your care at one place without wasting time in searching of records at many places. Establishing patient care should not be billed.

 

Established patient is one who has been seen by the provider with in the past 3 years.

 

We hope we have explained the difference between establishing care and established patient clearly.

 

Please feel free to write if you have any question.

 

Thanks.

Charlene Posted Fri 27th of December, 2019 08:54:42 AM
Would it be appropriate to code a preventive visit (99395-99397) when the patient's overall health is being assessed and screenings ordered based on the lack of and/or time for such screenings. Also, would it be appropriate to code established E&M at the same visit when monitoring of chronic conditions and Rx given?
SuperCoder Answered Mon 30th of December, 2019 03:27:44 AM

Please find below the answers to your questions:

 

  1. Preventive services include exams, shots, lab tests, and screenings. So, it would be appropriate to code a preventive visit (99395-99397) when the patient's overall health is being assessed and screenings ordered.
  2. Yes, you may report new or established patient E/M at the same visit when monitoring of chronic conditions and Rx given.
  3.  Medicare Part D covers prescription drugs that may help you treat a disease or condition found by preventive screening tests (e.g. high cholesterol).

 

Hope this helps.

 

Thanks.

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