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New vs. Established Patients

  1. Drs. A and B were both members of a same-specialty practice that closed, and now both physicians join a new same-specialty practice with a new NPI. Patient Jones saw Dr. A at the original practice and, within a three year period of seeing Dr. A, now sees Dr. B during a first visit to the new practice.

    Please clarify whether Patient Jones is considered a new patient to the new practice and to Dr. B., since Dr. B was formerly in a same-specialty group with Dr. A.

    Answer:
    Dr. A and Dr. B are now members of a new practice, and their prior relationship as colleagues in the former practice is no longer in effect. If the patient sees Dr.B in the new practice, the patient is considered new to the practice and to Dr. B, who has not personally seen the patient before. If the patient had seen Dr.A in the new practice, the patient would have been considered established to Dr. A, who had personally seen the patient within the prior three years. Updated 8/29/2017
     
  2. Please clarify appropriate billing by the same physician who is enrolled in Medicare under two different specialties: emergency medicine and internal medicine. If this physician sees an ER patient and then provides f/u internal medicine care in either the inpatient or outpatient environment, is the patient then considered new to the provider in the internal medicine practice?

    Answer:
    Although a physician may have two specialty designations, he/she is still considered to be one enrolled Medicare provider. The patient is considered known to the provider as a result of the initial ER encounter.

    Only one E&M service is payable per patient per day to this provider. The provider may bill an initial hospital service on that date, but not in addition to ER care, and may also bill for inpatient hospital care on subsequent inpatient DOS.

    When the provider sees this same patient in an outpatient internal medicine environment, the patient is known to the provider and services must be billed for an established patient.

    A patient can only be new to a provider once in a three-year period. ED visits and inpatient care are not categorized as “new” or “established” visits, but through the ED and inpatient care encounters, the physician and patient are now known to each other. As such, f/u medical care should be billed as an established patient visit. Updated 8/29/2017
     
  3. When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

    Answer:
    An initial level of service in the office setting (99201-99205) requires 3/3 elements. When one element is not performed for a valid reason (e.g., a patient with dementia cannot provide any history), this must be documented in the medical record and may still be counted toward the appropriate level of coding. Unless there is a valid reason documented for the missing element, initial level of care expectations have not been met and the service is not billable. Since the initial office visit sets the timetable for the three year timeframe in which a patient is considered new vs. established, an established visit (99211-99215) cannot be billed in lieu of the initial visit. This does not apply to initial hospital care codes (99221-99223), since a patient is not considered new or established in the hospital setting. For initial hospital services that do not meet expected criteria, a subsequent hospital service code (99231-99233) may be used to bill the service. Updated 12/6/2017
     
  4. A patient is seen in the ED by a resident and referred to another specialty provider. Is the patient considered “new” or “established” to the specialty provider?

    Answer:
    Care provided by a resident is not billable to Medicare and not counted in considering whether a patient is new to a Medicare provider seeing the patient for the first time. An initial office visit to a specialty practice would be considered a new patient
    visit, if the patient had not been seen by any same-specialty group practice member in the prior three years. Updated 6/9/2017

  5. Regarding a problem as “new to the patient”: Does this mean if the patient has the diagnosis at the start of the visit (from this physician or another physician) that it is not new to the patient? Please clarify this change.

    Answer:
    When a patient’s problem has been diagnosed by one member of a same-specialty group practice, that problem is no longer considered “new” to other group members who may see the patient subsequently. When a patient presents with a “new” problem, it is considered new to the provider treating the patient during that encounter, but is not “new” to other same-specialty providers in the group who may see that patient during subsequent encounters. If the patient is seen for an recurrence or exacerbation of a previously addressed problem, the recurrence or exacerbation is again considered as a new problem. Updated 6/9/2017
     
  6. Does the concept of a “new patient” or “new problem” apply to patients treated in the ED?

    Answer:
    The concept of “new” vs. “established” patients does not apply in the ED. All ED patients, and their presenting problems, are considered as new, regardless of the patient’s history or the examiner’s prior experience with the patient. Updated 6/9/2017
     
  7. Is anticoagulation therapy included in the category of drugs requiring “intensive monitoring for toxicity”?

    Answer:
    Anticoagulation management is defined by specific lab tests and patient communications regarding dosage adjustment. This level of monitoring would not be considered as “intensive” and prescription of this drug, in most patients, will be associated with moderate level of risk. Updated 6/9/2017
     
  8. Please clarify whether telephone conversations on medication management can be counted into the level of MDM for the next OV. Can you please tell us if this is the case and also how would this be properly documented in the patient’s chart?

    Answer:
    Medication management is performed and documented as part of the face to face E&M service. If prior telephone conversations are reiterated during a face to face visit, and medication management is reinforced or modified, this can be included in the MDM assessment for the visit. Updated 6/9/2017
     
  9. Is referral to a specialty consultant considered as “additional workup” on the MDM table?

    Answer:
    Additional workup includes all requests by the provider to obtain further diagnostic information to help establish a final diagnosis and plan of care. This includes orders for diagnostic tests and requests for consultative input from other specialty providers. Updated 6/9/2017
     
  10. Is prescription drug management counted as ‘moderate’ on the table of risk when a medication is prescribed that is also available over the counter?

    Answer:
    Certain medications (e.g., Omeprazole) are available by prescription or over the counter (OTC) sale.

    Usually, these medications vary in dosage. When a provider prescribes such a drug at a dosage not available as OTC, credit can be assigned as moderate in the Table of Risk.

    When a provider prescribes an OTC medication that may have significant risk factors (e.g., daily aspirin) the risk may be assessed as moderate, depending on the patient’s overall clinical status, other comorbidities and other potential drug interactions. Updated 6/9/2017
     
  11. Please define a self-limited or minor problem as part of the MDM.

    Answer:
    A self-limited or minor problem is defined as a problem which will resolve with minimal, if any, medical intervention and without any serious prognostic implications. Examples: common cold, mild viral gastritis, small joint sprain. Updated 6/9/2017
     
  12. Can a provider get credit for moderate or high MDM when he/she recommends surgery but the patient refuses?

    Answer:
    When a provider recommends and discusses surgery with a patient, credit can be granted as either moderate or high, depending on the nature of the surgery. The patient’s refusal of the surgery does not negate the provider’s effort on this point. Updated 6/9/2017
     
  13. Where does a blood transfusion fall on the table of risk management options?

    Answer:
    Blood transfusion is associated with high risk, correlative to parenteral controlled substances or drugs requiring intensive monitoring. Updated 6/9/2017
     
  14. Can Pulse Oximetry (CPT code 94760) during the visit be counted in MDM as Review and/or order of tests/procedures in the medicine section?

    Answer:
    One point may be assigned for pulse oximetry as a medical test. Updated 6/9/2017
     
  15. What is the minimal time documented in reporting counseling codes (G0447, G0444) that state 15 minutes in the code descriptor?

    Answer:
    As with many time-based codes, there is an expectation that at least half of the suggested time should be spent performing this service. The provider, therefore, should spend at least eight minutes in this screening discussion and document the actual time spent. Updated 11/30/2017
     
  16. When a presenting problems falls in the moderate risk category, is it possible for a visit to be coded at the comprehensive (level 5) level of service?

    Answer:
    In addition to the presenting problem, other points are assigned under MDM (new vs. chronic problem, workup initiated, data reviewed) and these combine to establish overall complexity of MDM.

    Providers should be mindful that care rendered during an E&M service should be driven based on the presenting problem(s), to support the medical necessity of each element of care. When the presenting problem is straightforward, performance of a higher level of service is generally not warranted as medically necessary by Medicare standards. Hospital protocols are not the driving factors here; Medicare reimburses only for medically necessary care. Updated 6/9/2017
     
  17. If a provider recommends a prescription drug, but the patient refuses it or fails to fill the prescription at the pharmacy, would credit still be appropriate under MDM for “prescription drug management”?

    Answer:
    If the provider recommends a prescription drug and discusses it with the patient, this would qualify as prescription drug management, regardless of whether the patient agreed to the prescription or actually obtained and/or consumed the drug. Updated 6/9/2017
     
  18. For an established patient visit, during which history and examination are at the EPF level, but MDM is straightforward, would level 99213 be appropriate?

    Answer:
    In this scenario, 2/3 components met the EPF coding level and the visit could be coded as 99213.

    Since the MDM is straightforward, there may be a concern that the history and examination might have been more appropriate at the PF level, since the presenting problem should correlate to the medical necessity for the level of care. Updated 6/9/2017
     
  19. Please clarify how diagnoses are counted, when the primary diagnosis is a result of the secondary diagnosis, e.g., anemia due to chronic kidney disease.

    Answer:
    Both diagnoses count equally, since the provider must consider the implications of each in formulating a plan of care. Updated 6/9/2017
     
  20. Please define points allowed for a chronic problem (e.g., hypertension) as either stable or worsening.

    Answer:
    One point is allowed for review of a stable chronic problem, and two points are allowed for review of a problem that is unstable or worsening. Updated 6/9/2017
     
  21. Is uncontrolled diabetes with two other comorbidities considered high risk?

    Answer:
    The level of risk would depend on the degree to which the diabetes is uncontrolled. Moderate risk would be assigned to diabetes with mild progression (e.g., consistently elevated blood glucose levels), while high risk would be associated with evidence of severe progression (e.g., ketoacidosis or episodes of insulin shock). Updated 6/9/2017
     
  22. Please clarify points allotted for MDM and how the ultimate MDM category is achieved.

    Answer:
    Points are assigned relative to the patient’s problem, the data and records reviewed and the level of risk associated with the treatment plan. Two out of the three elements must meet the same MDM level in order to assign that level; when two or more elements score at a lower level, the overall MDM falls to the lowest level assigned. Updated 6/9/2017
     
  23. Please clarify new patient visits and consultations within a multi-specialty group practice.

    Answer:
    In multi-specialty groups, when patients are seen for the first time by a group member of a different specialty, each specialist may bill a first encounter with the patient as a “new visit”. When group providers of the same specialty see a patient for the subsequent care, the patient is considered “established”, since the first encounter has been performed by a same-specialty colleague in the group. Updated 6/9/2017
     
  24. When NPPs are employed by several different specialty groups in a multi-specialty practice, what are the rules for “new patient” billing?

    Answer:
    NPs are designated by CMS as specialty 50, regardless of the subspecialty area in which they practice. PAs are designated as specialty 97, and the same rule applies. CMS editing only permits one new visit per provider specialty type within a group over a three-year period.

    Since these are two different provider designations (spec 50 vs. spec 97), new visits by each within a three-year period may be payable. However, if the patient was seen in a multi-specialty practice as a new patient by a spec 50 working within IM, and then seen within three years by a spec 50 working within cardiology, the second new visit would be denied. If documentation submitted on appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. Updated 6/9/2017
     
  25. How does a plan for radiation therapy or chemotherapy affect the coding for the patient’s initial visit?

    Answer:
    Coding for an initial patient visit is based on the provider’s documentation of the patient’s history, the scope of physical examination and the medical decisions made as a result of the visit. Each of these elements must correlate to the level of detail that the provider finds medically necessary to address the patient’s problem(s). While chemotherapy and radiation therapy may increase the level of risk, all elements (history, exam, decision making) are included when selecting the correct coding for the service. Updated 6/9/2017
     
  26. If a patient is seen by a resident in the ED, and subsequently sees a physician in the office, is this considered a new or established patient for the physician?

    Answer: If the physician has not seen this patient within a three-year period, the office visit is considered a “new patient” visit. Services performed by residents do not count toward a patient’s status as “new” or “established”.  Updated 6/9/2017
     
  27. In a cardiology group, there are several specialty types (cardiology [06], electrophysiology [21] and interventional cardiology [C3]). If a patient has been seen as a “new” patient by one member of the group, how is a first visit with another group member billed, when the specialty type differs?

    Answer:
    As in all multi-specialty groups, when patients are seen for the first time by a group member of a different specialty, each specialist may bill a first encounter with the patient as a “new visit”. When group providers of the same specialty see a patient for the subsequent care, the patient is considered “established”, since the first encounter has been performed by a same-specialty colleague in the group. Updated 6/9/2017
     
  28. In a single specialty group (e.g., internal medicine), when a patient with a known history of diabetes is seen by a new group member, is this considered an initial visit, since the problem is new to the provider?

    Answer:
    In single specialty group practices, or practices in which “covering” providers are seeing established patients, known diagnoses are not considered as new to other same-specialty examining providers. The diagnosis and other details of the patient’s status are presumed to have been incorporated into the medical record by the original provider in the group, so follow-up care for this diagnosis is not considered as treating a new problem. Please refer also to Medical Decision Making FAQs above. Updated 6/9/2017
     
  29. If a provider who is credentialed with Medicare is starting to see patients at a new practice, and the patients were previously known to the provider from a prior practice, are these patients now considered to be “new” or “established” to the provider?

    Answer:
    If the provider has seen the patient within the prior three years, the patient is not new to the provider, who should be submitting claims for an established patient, regardless of which practice the patient is being seen in. Updated 6/9/2017
     
  30. When a pulmonologist refers a patient in a group practice to another specialist in sleep disorders, claims are being denied. Please explain.

    Answer:
    Pulmonary medicine is recognized by CMS as a specialty, but there is no recognized specialty for “sleep disorders”, which is usually a focus of pulmonary medicine. As such, the patient would not be considered “new” to either of these group members, if previously seen by the other one. Updated 6/9/2017
     
  31. Inpatient professional billing (POS 21): If the hospitalist covering the oncology service performs and bills for an inpatient E&M visit and then asks for the medical oncologist to see the same patient, same day, can the medical oncologist also bill an E&M for his/her service?

    Answer:
    If the hospitalist’s specialty designation is different from the medical oncologist’s, then two E&M services may be payable. The medical necessity for both visits needs to be clearly indicated in the medical records. Updated 6/9/2017

  32. When a provider is a member of more than one group practice and sees the same patient for first visits to each of the practices, should the provider bill a new patient visit for each?

    Answer: A new patient visit is payable once within a three year period to a provider, regardless of whether the provider is a member of a single group or multiple groups. When a new patient visit claim has been paid to a provider within a three year period, subsequent visits with that patient must be billed with established patient care codes, whether the subsequent care takes place at the same or a different group practice. Updated 2/20/2019

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New vs. Established Patients
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