How Coding Guidelines Define “New Patient”

The distinction between new patient and established patient is vital for correct evaluation and management (E/M) code assignment, coding compliance, and reimbursement.

CPT defines an established patient as one who “has received a professional service from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and sub-specialty who belongs to the same group practice, within the past three years.”

Within the context of E/M code selection, CPT defines a professional service as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s).” The “face-to-face” nature of a professional service is important: CMS policy  confirms, “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.” A patient is new, for instance, if the physician interpreted test results two years earlier, but had provided no face-to-face service to the patient within the previous three years.

The second requirement addresses patient status relative to other providers in a group practice. When a patient becomes established with a physician who works in group practice, the patient is established with all physicians of the same specialty/sub-specialty in the group. The AMA allows an exception for new physician’s seeing for the first time a patient established to the practice. CPT Assistant, November 2008, features the following Q&A:

Question: Can new physicians who come on board to a group practice with their own tax identification numbers charge a new evaluation and management code for patients they see?

Answer: According to CPT guidelines, a new patient is one who has received no professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Also, if a physician is new to this group practice and had never seen or billed a patient previously though his tax ID number, this should be considered a new patient for the purposes of this physician billing for his evaluation and management service.

Not all payers agree with this logic: inquire with your individual payers before billing as new any patient who is established with another physician of the same specialty/sub-specialty within a group.

Two providers in the same practice may both classify a patient as new, if they see the patient for different reasons and the providers are of different specialties recognized by the Centers for Medicare & Medicaid Services (CMS). For a list of Medicare-recognized physician specialties, visit the CMS website. CPT guidelines specify, “When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same sub-specialties as the physician.”

For example, a general surgeon in a large multiple-specialty practice sees a patient in 2015 to remove some skin lesions. In early 2017, the same patient sees an internist—who is a member of the same multispecialty practice as the surgeon who previously treated the patient previously—for a new condition. Because the surgeon and internist (who are of different specialties) saw the patient for unrelated problems, the internist may report the initial visit using the new patient codes (e.g., 99201-99205).

If a provider is covering for another provider, a patient’s status is relative to the provider who is unavailable (not the covering provider). For example, Dr. Smith is covering for Dr. Jones, who is on a family vacation. Patients who are established with Dr. Jones would be treated as established with Dr. Smith, even if Dr. Smith has not seen the patient previously.

Finally, note that location doesn’t affect a patient’s “new” or “established” status. CPT Assistant (June 1999) explains:

Consider Dr A, who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A.

In other words, where the patient is seen doesn’t matter. If the provider treats a patient face-to-face service within the previous three years (in any location), that patient is established (in all locations).

6 Tips to Get Paid by Medicare

Accepting Medicare is one of many ways in which physicians can expand their practices. That’s because even despite often having a lower fee schedule, Medicare tends to pay consistently and promptly, making it easier for practices to grow.

However, choosing to accept Medicare isn’t a ‘one and done’ decision. Instead, it requires a thoughtful approach to ensure that practices are paid appropriately, maintain adequate cash flow, and safeguard revenue so auditors don’t try to eventually recoup that money.

Frank Cohen, director of analytics at Doctors Management, LLC in Spring Hill, Florida, provides these six tips for practices that are new to Medicare:

1. Hire a nurse practitioner or physician assistant

The cost-to-revenue ratio is significantly lower when non-physician practitioners (NPP) treat Medicare patients, says Cohen. This means it’s ultimately more profitable when NPPs see these patients. This strategy also allows physicians to fill their schedules with patients whose insurance pays more per relative value unit. This allows the practice to accept and treat Medicare patients without having to drain all of the physician’s time and resources.

2. Be strategic when scheduling patients

For example, set aside a certain number of daily slots for patients with Medicare, Medicaid, and private insurance. Because Medicare often pays the lowest, consider setting strict limitations for the number of Medicare patients seen in a single day or week, says Cohen. Balancing the schedule in this way creates a cashflow equilibrium.

3. File clean claims every time

“Do it right on the front end so you’re not subject to an audit three years down the road,” says Cohen. “Clean claims are the secret to not only making—but keeping—money in this industry.”

Filing clean claims may require physicians to hire a certified medical coder. They’ll also need to budget for that individual’s ongoing continuing education. If the physician can’t afford a certified coder, then it’s best to outsource the coding function to a reputable company, says Cohen.

(Here’s a checklist to help you decide on your medical billing needs: Is Outsourcing Your Medical Billing the Right Choice?)

4. Establish a compliance plan—and follow it

The Office of Inspector General (OIG) provides guidance for individual and small group physician practices to help them conduct internal monitoring, implement practice standards, develop corrective action and more. Following a documented compliance plan helps physicians stay on track, and it mitigates risk for denials and recoupments, says Cohen.

5. Work with your practice management vendor

Because Medicare’s National Coverage Determinations, Local Coverage Determinations, and National Correct Coding Initiative edits are completely transparent, physicians are most successful when they work with their practice management vendors to ensure that this information is loaded on the front end. This enables practices to validate claims prior to submission. Many systems also offer coding checks that validate procedural codes and modifiers.

It’s difficult to implement this same type of checks and balances with private payers, says Cohen. “The problem with private payers is that there’s still a lot of black box editing that goes on,” he says, adding that he recently had to look 22 pages deep into a payer’s website to find its payment policy.

6. Hire an external auditor annually

Under these self-disclosure and payback policies, the government and private payers are expecting physicians to hire an external auditor, says Cohen. External auditors can easily identify billing and compliance risk that could be potentially catastrophic when left unaddressed, he adds.

Choosing to accept Medicare can help physicians grow their practices, but only when implementing a strategic approach to stay profitable. This includes careful consideration of staffing, scheduling, billing and auditing.

How exactly is Medical Coding different from Medical Transcription?

How exactly is Medical Coding different from Medical Transcription?

The terms like Medical coding and medical transcription are often used interchangeably, despite the fact that they are somehow different from each other. Nevertheless, the these terms represent careers that are indispensable for the medical profession. All these careers need an adequate understanding of medical terminology, physiology, and anatomy.

Medical coding and transcription are interconnected professions that are pivotal for every healthcare provider. A better perception of the job description of each of those critical professions will surely help in the development of the careers which will be reflected in a better quality of the health care services offered.

 

What is Medical transcription and what are its opportunities?

Medical transcription applies to the profession which is centered on the process of conversion of audio reports recorded by physicians and other healthcare providers, such as nurses, into written or typed text format.

Medical transcriptions play a crucial factor in the healthcare industry. Medical transcribers need to have sound knowledge of medical terminology, physiology and anatomy, Medical transcribers role is to translate medical records written by doctors and other medical professionals related to this field. Medical transcribers need to have good working knowledge of computer systems and have a right level of typing skill. Medical transcribers start by working in a healthcare setting, and after several years of work experience, they may work from the house or establish their transcription businesses.

 

What is Medical coding and what are its opportunities?

Medical Coding provides codes to diagnose the procedures which assist in financial settlement from insurance companies, IT companies, government agencies and consulting firms. Medical Coding is known as insurance coding in the healthcare industry. This industry produces medical coders who specialize in coding after a comprehensive training course and a certification process. Medical coders work in different places right from Hospitals, clinics to dentists and should have information on medical terminology and physiology.

 

Major difference between Medical Transcription and Medical Coding

Medical transcription includes translating laboratory reports or other medical data as written by medical personnel. Medical coding is converting prescriptions of medical data into numeric or alphanumeric codes to assist the medical billing process. The Medical Transcriptionist assures the notes of the medical personnel are comprehensible while the coder provides that the coding needed for billing insurance organizations are entered correctly.

Why Get Certified

Whether you are brand new to the medical coding and billing field or are a seasoned coder and biller, having a medical coding and billing certification will set you apart.