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New vs. Established Patient

John Posted Fri 14th of February, 2014 12:25:34 PM

AMA CPT manual describes a profesional service as "face to face" service rendered in the last 3 years. It goes on to state that a new patient is one that has not received any professional service from the physician or another physician in the same group practice etc. My question is if a professional service is described as face to face, we should bill for a new office visit 99204 when the only other service in the last 3 years was a 93306-26. The doc interpeted an echo while this pateint was in the hospital. This was not a face to face visit. We are getting multiple denials stating that our office visit should have been billed as established and is based on a charge from the hospital setting where the doc had interpeted a test. No interaction with the pateint whatsoever. Any clarification would be helpful.

SuperCoder Answered Mon 17th of February, 2014 10:54:03 AM

Your interpretation of new patient matches that of CMS in MCPM, Chap. 12, Section 30.6.7 (see last sentence): “Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed 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. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.” (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf)

Sharing this quote, along with CPT’s definition of professional as face-to-face, with the payer may help with an appeal if the payer follows Medicare rules or does not provide its own specific guidance on use of new patient codes. Third party payer rules on the definition of new and established can vary.

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