Avoiding Denials for New vs. Established Patient
Billing for new patients requires three key elements and a thorough knowledge of the rules. A persistent concern when reporting evaluation and management (E/M) services is determining whether a patient is new or established to the practice. New patient codes carry higher relative value units (RVUs), and for that reason are consistently under the watchful eye of payers, who are quick to deny unsubstantiated claims. Here are some guidelines that will ensure your E/M coding holds up to claims review.
New patient visits used to be easy to distinguish from those with established patients. A new patient was someone you had not previously seen or perhaps someone for whom you did not have a current medical record. Today, like so many other aspects of health care delivery, differentiating between new and established patients and coding your services accordingly has become more complex.
By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years. In addition to this definition, the Centers for Medicare & Medicaid Services (CMS) adds in Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7): 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.
- Professional Service: When physician coders see this, we automatically think of modifier 26 Professional services. This leads us to think that if the provider bills a claim for radiology or labs, and sees the patient face to face, an established patient office visit must be billed. This is not true, per the aforementioned CMS guidance. If the provider has never seen the patient face to face, a new patient code should be billed. Example: A patient presents to the ED with chest pain. The ED physician orders an electrocardiogram (EKG), which is interpreted by the cardiologist on call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. The patient is sent home and asked to follow up with the cardiologist next week for coronary artery disease. At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, but did not see the patient face to face.
- Three-year rule: The general rule to determine if a patient is “new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.
- Different specialty/subspecialty within the same group: This area causes the most confusion. For Medicare patients, you can use the National Provider Identifier (NPI) registry to see what specialty the physician’s taxonomy is registered under. For payers, this usually is determined by the way the provider was credentialed. Those who are part of the credentialing process must understand how important it is to get the provider enrolled with the payer correctly. Denials will ensue if this is not done correctly.
If one provider is covering for another, the covering provider must bill the same code category that the “regular” provider would have billed, even if they are a different specialty. For example, a patient’s regular physician is on vacation, so she sees the internal medicine provider who is covering for the family practice doctor. The internist must bill an established patient code because that is what the family practice doctor would have billed.
There are some exceptions to the rules. For example:
- In the emergency department (ED), the patient is always new and the provider is always expected to get the patient’s history to diagnose a problem.
- Some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to her becoming pregnant.
- Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.
If a new patient claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal.
E2E Medical Billing Services has an experienced medical billing and coding team who accurately identifies patient category i.e. New or Established and applies E/M codes accordingly. To know more about our medical billing services you can call us at 302-231-1286 or write to us at email@example.com