Forum - Questions & Answers

Aug 5th, 2010 - lmsmith

What CMS calls a new patient

Providers have individual NPI - claims are filed with individual providers NPI but also show the hospital tax ID number and NPI for the facility -

We have multiple specialty/outpatient services umbella'd under this facility. Can a patient be seen by multiple different practices for initial - new patient visits as long as they have not been seen there before. Or does the patient only qualify as a new patient for the first specialty he is seen by????

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Aug 10th, 2010 - Codapedia Editor 1,399 

new versus established

For the professional fee, patients seeing physicians of different specialities are new patients. For the facility, I believe they are established.

Perhaps someone with more facility knowledge will comment.

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Aug 10th, 2010 - jschmutz   323 

CMS Definition of a New Patient

There aren't many E/M codes that would be used in a facility that the NP/est pt would apply. The E/M's that are affected by New Patient or Established Patient are usually outpatient codes.

The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7) now defines “new patient” for the E/M visit code and reads as follows.

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. 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.


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Aug 11th, 2010 - Codapedia Editor 1,399 

New patient for facility

When the facility charges only an E/M service (translated into a revenue code) because the pt. is seen in the ED, or in a multi-specialty group and the group is provider based, I believe the question is different for the facility than for the provider. But, I hope someone with facility experience will chime in.

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