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What Makes A New Patient “New”?

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:

  1. Professional Service (not modifier 26)– If the provider has never seen the patient face to face, a new patient code should be billed.
  2. 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.
  3. 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 example:

  • 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)

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It’s the holiday season….time to spread the Flu!

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With all the weather changes we have experienced in the south over the past few months, getting the flu has been the last thing on anyone’s mind.  80 degree temps here in Kentucky in November is unheard of!  We’ve all been taking advantage of getting out in the fresh air (flu?  what flu?).

Well, now we are experiencing our first “Arctic Blast” and my first trip to Kroger this week resulted in witnessing probably the most embarrassing thing we as parents experience….projectile vomiting from a child in the grocery store.  Okay, maybe not the most embarrassing thing in the world but one that certainly had me running for the hand sanitizer and masks (no-I didn’t stick around to help).

And yes, remembering that in fact, the flu season is upon us.

Guidelines for Billing Influenza Vaccines

Medicare pays for one seasonal influenza virus vaccination per influenza season (12 months do not have to pass). Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Medicare will pay both administration fees when a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day. Report ICD-10-CM diagnosis code Z23 Encounter for immunization when an individual receives both vaccines, but report separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines.

Medicare Payment Allowances for this flu season (8/1/2016-7/31/2017)

CPT® Code Payment Allowance
90630 Influenza split virus vaccine, quadrivalent (IIV4), preservative free, for intradermal use $20.343
90653 Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use $37.383
90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use Pending
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use Pending
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use $17.717
90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6–35 months of age, for intramuscular use Pending
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Pending
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use $42.722
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use $26.876
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use $40.613
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

*NOTE-Claims for this code must be held until 1/1/17

$22.936
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use $26.268
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use $19.032
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6–35 months of age, for intramuscular use $9.403
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use $17.835

 

HCPCS Level II Code Payment Allowance
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) $16.284
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) $16.284
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin) Pending
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Pending
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Flu Vaccine Adult – Not Otherwise Classified: Payment allowance is to be determined by the local claims processing contractor.

The payment allowance for some codes is still pending. Check the CMS website periodically for updates.

Resources:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2016-12-08-eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending#_Toc468862699

 

 

ICD-10 Walking Through the Workflow

With less than a year to go until the ICD-10 code set implementation deadline, physician practices should be pursuing a comprehensive plan designed to ensure a smooth coding transition with minimal cash flow disruption.

A key step in any ICD-10-CM transition strategy is to conduct a detailed assessment of existing workflows and processes to determine which elements will require modification, according to Bess Ann Bredemeyer, a consulting director with McKesson Business Performance Services (BPS).

By identifying each point in the claims lifecycle that ICD-10- CM will touch, appropriate adjustments can be made and simulations conducted to test the new processes against real-world conditions.

“The best way to proceed with an assessment is to begin at the patient encounter and then move through to the claim drop and denial management,” Bredemeyer said. “That way you won’t miss anything.”

Clinical Documentation  Whether the clinical documentation is sent directly to a coder or to data entry personnel, it is also important to ensure that any changes in National Coverage Determinations (NCDs) and payer’s Local Carrier Determinations (LCDs) are incorporated and reflected in the claim. A good approach includes:

  • Identifying the top 50 most utilized diagnoses codes
  • Evaluating where additional documentation will be required
  • Mapping out modifications to support appropriate reimbursement
  • Updating charge tickets, super-bills and other revenue cycle tools

This is a Test  With all the elements theoretically in place, it is critical to begin testing your new workflow to determine if it can handle ICD-10-CM. Code audits can assess both clinical documentation and coding to determine whether the claims should come through clean or not. A real-world testing process may also reveal previously unknown problems that would otherwise remain hidden until the ICD-10 go-live.

Don’t Be Denied  Because of the complexity of ICD-10-CM and the sheer magnitude of the change, it’s reasonable to assume that even the best-laid plans may encounter some unexpected problems. For that reason, it makes sense to be prepared for a rise in denials. For physician practices, that means ensuring that staffing is adequate to manage an increase in volume, and that problems will be quickly identified and remediated.

“There is no denying that the transition to the new code set will require planning and resources to mitigate the burden of change,” Bredemeyer said. “That’s why you should get started now on developing a workflow analysis impact assessment that will help you develop a detailed ICD-10 timeline and budget.”

Article Resource:

ReveNEWS, Industry Spotlight, “Walking Through the Workflow- An Important First Step,” November 2013 edition located on the McKesson ReveNEWS website

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