A patient makes an appointment at your clinic and “has never been seen before”, you bill a new patient visit only to have the payer reject the claim, stating, “New patient qualifications have not been met”.
So, what went wrong? Not all Evaluation and Management (E/M) codes fall under the new (versus established) categories. For example, if the patient presents through the Emergency Department, the patient is always new, and the provider is always expected to get the patient’s history to diagnose a problem. However, in the office setting, the patient sees their primary provider routinely. The provider knows- or can quickly access- the patient’s history to manage their chronic conditions, as well as make decisions on recent problems.
The definition of a new patient in the CPT code book is: “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” In addition to this definition, CMS adds “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.”[i]
Three key components that make up a new patient are:
- Professional Service (not modifier 26)– If the provider has never seen the patient face to face, a new patient code should be billed.
- Three-year rule- the general rule to determine if a patient is “new” is to check to see if that patient has been seen in the past three years. Check your dates on this-if the patient was seen the last time in May of 2015 and its March of 2018, it hasn’t been three years, according to the payer.
- Different specialty/subspecialty within the same group is possibly the most confusing. For Medicare patients, use the NPI registry to see what specialty the physician’s taxonomy is registered under. The credentialing process is of upmost importance in ensuring no denials happen due to improper credentialing.
What happens when doctors switch practices?
If a doctor changes practices and takes his patients with him, the provider cannot bill for the patient as a new patient based on the “new” tax ID. The tax ID doesn’t matter because the provider has already seen these patients and has established a history. Just because the patient is being seen in a new facility, that patient is still seeing the same provider.
What happens when a provider sends the patient to mid-level provider?
When an MD or DO sends a patient to a mid-level provider (Nurse Practitioner or Physicians Assistant) and the visit is not an incident-to, the mid-level provider could bill a new patient code if they are a different specialty with different taxonomy codes. An example would be a family practitioner and the mid-level sees hematology patients. Since the specialty is different, the mid-level could bill as a new patient visit. However, if the mid-level is also considered family practice, then a new patient visit code could not be used.
Of course, in billing there are always exceptions to the rules.
- For some Medicaid plans, obstetric providers need to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to the patient’s pregnancy. Make sure you check your own local rules and Medicaid plans if you are billing obstetrics.
- Hospitalists and Internal Medicine providers are the same specialty according to Medicare, even though each has a different taxonomy code.
If a new patient claim is denied, look to 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 by checking the NPI registry website. It’s always helpful to know how the provider is registered with the payer denying the claim. If in researching all of this, there isn’t any substantiating evidence to support the denial, appeal the claim.
[i] Medicare Claims processing manual, chapter 12-Physican/Nonphysician Practitioners (30.6.7)