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New vs Established Patient

Rhonda Posted Wed 09th of October, 2019 10:06:06 AM
We are an urgent care. What is Medicare's rule on new vs established. We coded a new patient and they denied stating our midlevel provider saw this patient in the ER where he used to work last year. Two different entities, two different tax id numbers. Is this correct? How would we know this patient has been seen before by the provider?
SuperCoder Answered Thu 10th of October, 2019 02:30:38 AM

Hi Rhonda,

Thank you for your question.

Location doesn't matter. The fact that the patient was seen by this provider within the past three years matters. The only time he wouldn't be established is if there was no face-to-face service prior.

You should not use place of service (POS) as an indication of new versus established patient. Based on CPT®’s established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location. Practices often think they can bill a patient as "new" because the patient is new to their practice. But remember, the same physician already saw the patient - just in another location.

Because POS is irrelevant to this case, even if the physician saw a patient in a different practice, the next time the provider at the new practice sees that patient he is an established patient.

Even though this patient is new to the office, you should report an established patient office visit.

NOTE:

If the provider treats a patient during a face-to-face service within the previous three years (in any location), that patient is established (in all locations). Where the patient is seen doesn’t matter. This includes patients who are first seen in the hospital. When arriving to the office, they are also established patients. Also, because the patient is considered established to your new physician, that patient is considered established to all the physicians in his new practice who are of the same specialty and subspecialty.

Hope it helps.

Rhonda Posted Thu 10th of October, 2019 09:14:27 AM
"Even though this patient is new to the office, you should report an established patient office visit." Like in this case, we have no idea who has been seen in an ER since we are not affiliated in any way. We are independently and privately-owned urgent care. Are we wrong to bill "new" and then refile when Medicare tells us they are not new? Thank you!
SuperCoder Answered Fri 11th of October, 2019 05:14:33 AM

Hi Rhonda,

True. Even though this patient is new to the office, you should report an established patient office visit because POS is irrelevant to this case, even if the physician or any other physician of same specialty or sub-specialty saw a patient in a different practice/place, is an established patient.

Feel free to ask for any further query.

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