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new vs established visit between multiple NPs providing different care

Charlene Posted Mon 14th of October, 2019 07:07:30 AM
#1 Our practice is a multispecialty group. We have PAs who only work with one provider such as orthopedic, pain mgt, primary care or urgent care. Does the PA assume the specialty of the provider they work with? If a patient has seen a PA in ortho department, is the patient new or established if they see a PA in our primary care department? #2 We have a clinic where the physician recently left. A new PA is providing care in the clinic now. Are the patients seen in the clinic new or established?
SuperCoder Answered Tue 15th of October, 2019 10:11:14 AM


Thanks for your question.

According to CMS,

"a new patient is defined as an individual who has not received professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years". 

  1. The speciality designation of an PAs determines whether patient is new or established. If the physician initially sees the patient, for example in Internal Medicine and then the PA follows up and refers to Orthopedics where the patient is seen by the Orthopedics physician, in this case you can bill a new patient visit for the Orthopedics physician.
  2. Patients who are seen by a new PA and who do not transfer care from your group within three-year time frame are reported as established patient encounters. In this scenario, the patient's status is determined by group identification, the time frame since the last encounter and the speciality of the physician providing care.

Hope this helps.


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