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New Patient Services (Q&As)

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For this document, the term "physician" means both the physician and the non-physician practitioner unless otherwise noted.

Q1. If a patient is seen for the first time in a practice and both a preventive visit and an Evaluation and Management (E/M) visit are provided at the same encounter, is the preventive medicine visit considered the new patient portion and the E/M visit considered established patient?

A1. Medicare states that a patient is a new patient if the physician has not provided any professional services within the previous three years. This includes not only the individual physician but also a member of the same group with the same specialty. In the above situation, the preventive visit (whether covered or non-covered) does not preclude billing a new patient visit for the covered portion of the service as long as all requirements are met. You can find more information on new patients in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.7. For more information on billing preventive services, please see the CMS IOM 100-04, Chapter 12, Section 30.6.2.

Q2. Is a neurosurgeon and neurologist considered the same specialty by Medicare to determine whether a patient is new or established?

A2. A provider designates his/her specialty when enrolling with Medicare. The 855 I Medicare Enrollment Application, Physicians, and Non-Physician Practitioner (NPP) shows that neurology and neurosurgery are separate specialties. A physician chooses the specialty under which to enroll. A NPP enrolls under his/her designation.

Q3. Our clinic has multiple locations. Our internal medicine specialists are in separate locations with separate charts. Can we bill a new patient visit when the patient sees the physician on Main Street for the first time even though the patient previously saw another physician in our office on 1st Street? The physician on Main Street has never seen the patient before and does not have any notes of previous visits. If we bill both services as new patient services, will we need to worry about any post-payment audits?

A3. Medicare views physicians within the same group with the same specialty as the same person. We determine whether physicians are members of the same group based on the Tax Identification Number. If both locations are under the same Tax ID, then Medicare will deny the second new patient visit procedure code received within the three-year period. There will be no post-payment review of the denied services.

Q4. If we do not provide all three of the key components (history, exam, and medical decision-making) for an initial visit, do we bill a subsequent care code or a not otherwise classified (NOC) code.

A4. The physician should look at the documentation of the services rendered. Chapter 12, Section 30.6 B2 of the Medicare Claims Processing manual states that, "In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim." Procedure code 99499 is the NOC for E/M services. A subsequent or established patient procedure code is not appropriate since the physician had not previously seen the patient.

Submit the claim with 'additional documentation available upon request' in loop 2400 of an electronic claim or in field 19 of a paper claim. We will develop for the medical records.

The provider may also choose the procedure codes based on counseling/coordination of care when the situation meets the requirements. You can find more information on counseling/coordination of care in the Current Procedural Terminology (CPT) and in the CMS IOM Publication 100-04, Chapter 12, Section 30.6.1 B & C discuss the requirements.

Q5. Is a patient new to the examiner or the same specialty in a group?

A5. If another physician of the same specialty in the same group had seen the patient within the last three years, then they are an established patient.

Q6. A neurosurgeon provided an inpatient consultation then saw the patient after discharge in the office. Is the patient a new patient?

A6. No. Since the physician saw the patient within the previous three years, they are an established patient.

Q7. We have a very large group with different tax numbers. How do we decide new patient versus established patient?

A7. Medicare views physicians within the same group with the same specialty as the same person. A group is comprised of members having the same tax identification number. If there are different tax identification numbers, the physicians are not part of the same group for Medicare billing .

Q8. Can the NPP see a patient new to the practice and bill under their supervising physician's provider number when the situation meets the incident to guidelines? How often does the physician need to see the patient when NPP is billing incident to? Does the physician have to be in the office suite to bill incident to?

A8. When the NPP sees a patient new to the practice, the service is billed under the NPP provider number. The following reference does not provide any specific timeframe. The physician must be in the office suite in order to bill the services under the physician provider number.

The CMS IOM Publication 100-02, Chapter 15, Section 60.1 B shows the requirements for incident to services. One of the requirements is that the services are furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency that reflects his/her active participation in and management of the course of treatment.

Q9. Does the three year time period for billing a new patient, go back from the date of service?

A9. Yes, the time period is from the date of service.

Q10. Doctor A is new to our group. If a former patient sees Doctor A under our group, is this patient new or established? If the former patient has a visit with Doctor B, in our group with the same specialty as Doctor A, is the patient new or established?

A10. If Doctor A sees his/her former patient, the service is an established patient visit. Doctor A's NPI shows the provider has seen the patient within the previous three years. If the patient sees Doctor B under the new group with the same specialty without seeing the Doctor A first under the new group, then the patient is considered a new patient because the Tax ID is different.

Q11. The patient sees the family practice physician in the group. The family practice physician sends the patient to the general surgeon. The service is not a consultation. Can the surgeon bill a new patient visit?

A11. The surgeon would have a new patient visit only if the surgeon has not seen the patient within the previous three years and they are not the same specialty as someone else in the group that has seen the patient within the previous three years.

Q12. The family practitioner sent the patient to the surgeon for surgery. The surgeon has asked the family practitioner for a pre-operative clearance. The service does not qualify as a consultation. Does the family practitioner bill as a new or subsequent visit?

A12. The family practitioner has a subsequent visit code since they have seen the patient within the previous three years.

Q13. I know that if a physician with the same specialty within the same group sees the patient, this would be a subsequent patient. How is this determined? Our provider offices are on opposite sides of town and do not share medical records.

A13. Members who share the same Tax ID are part of the same group. The location of services does not make a difference.

Q14. Physician A saw the patient within the previous three years for hypertension. The patient is now coming into the office with a new problem, diabetes. Can we bill a new patient visit procedure code because this is a new problem?

A14. No. If the patient has received professional services from the physician or a member of the same group with the same specialty in the previous three years, then you would bill any office or other outpatient services as an established patient procedure code.