new / established patient

We are a specialty group with many doctors. I am trying to determine if I can bill as a new patient or if I must bill as an established patient. Here is the scenario; One of the doctors is called to the hospital in an inpatient setting for a consult. One year later that patient is referred to our practice for an evaluation by the PCP. Can I bill as a new patient or do I have to bill as an established patient because the doctor performed a consult while in the hospital?

visit

What was the specialty designation for the physician seeing the patient in hospital? If same specialty/same practice you have an established patient (a professional service, face-face by same physician or same specialty, same practice, seen within 3 years). If the physician seeing them in the hospital is a different specialty designation, you have a new patient if you or member of same specialty/practice has not seen this patient before or within 3 years.

new/established

All the doctors are the same specialty. It was mentioned to me that if the doctor is consulted in an inpatient setting, the 3 year rule would not apply. Are you saying the 3 year rule applies regardless of the place of service?

est pt

The 3 year rule is not based on site of service, it is determined by same specialty/same practice. If any of the doctors, same specialty, same practice performed a face-face professional service visit with the patient within 3 years, the patient is established.

initial hospital services are not defined as new or established

The initial hospital services codes can be used as often as the patient is admitted: now, by the admitting physician with the AI modifier and by the consultant without a modifier. If a Medicare patient is admitted in June, and cardiology is consulted, bill with 99221--99223 series of codes. If readmitted the following June, and cardiology is asked to see the patient, bill again with 99221--99223 series of codes. New or established is irrelevant, because the initial hospital services are not defined as new or established.

what about low level visits?

[The initial hospital services codes can be used as often as the patient is admitted: now, by the admitting physician with the AI modifier and by the consultant without a modifier. If a Medicare patient is admitted in June, and cardiology is consulted, bill with 99221--99223 series of codes. If readmitted the following June, and cardiology is asked to see the patient, bill again with 99221--99223 series of codes. New or established is irrelevant, because the initial hospital services are not defined as new or established.]

Editor- Are you sure about that 221-223 receommendation? What about the low level visits??? I thought you were suggesting the use of the subsequent codes for initial visits that don't meet for 99221 ;-) Any word from CMS?

Follow up after initial hospital service

I re-read the initial question: Yes, these services one year later in the office, for Medicare patients, are established patient visits.

CMS did clarify that if the initial hospital service done by a consultant did not meet the criteria for a 99221, bill with subsequent hospital visits, even if the initial was not billed by that MD.

Prove it!

[ CMS did clarify that if the initial hospital service done by a consultant did not meet the criteria for a 99221, bill with subsequent hospital visits, even if the initial was not billed by that MD.
]

Do you have that in writing?

I'm not making it up, I promise

CMS released a new MedLearn Matters article on Friday of last week. I'll post it to the article on Codapedia called:

UPDATE CMS ELIMINATES PAYMENT FOR CONSULTS 1-1-2010