new provider new patient

we had a new M.D. join our group in Aug 2014 we received a denial from BCBS today stating "pt has not met new pt qualifications please rebill with est pt code." when I called bcbs they stated that the physician had seen this pt while she was employed with the previous group and so therefor our group could not bill for a new pt code.... in 16 years of billing I have never come across this can someone help me please

re: new provider new patient

since the new CPT® codes came out, they've been much more scrutinizing about that part. To use the "new Clt/Pt" coding there has to be a new provider, or at least three yrs since seen by someone in the same provider group. Someone else might be able to provide a clearer picture than I on that, if that info is insufficient?

re: new provider new patient

It may have to do with the providers NPI # even though you are billing with a different tax ID # for your practice, I thinking thats why BCBS is stating that. I don't think a provider gets a new NPI # even though they may switch practices, but that is interesting, in my 7years as a coder I have never come across this either. Not sure how to fix that except to call BCBS and ask if it makes any difference that the provider is under a new tax ID#,therefore the patient is a new patient to your practice thts my understanding per the CPT® guidelines and i would certinley point that out as most group practices bill under the same tax ID# even tho a provider NPI # does not change. Would be interesting to hear anyone else's take on this:)

re: new provider new patient

correct the provider does not get a new npi # but I would think it should go based off the tax id# since we do bill as a group but according to BCBS that is not how it works. was just wandering if this was something new since I have never come across it

re: new provider new patient

It's not a new denial, I have come across it many times before when a provider in the same locale leaves one group and joins another. If the patient is not a new patient to that particular provider, then bill as established. You can try appealing, but I never had much luck with that. Or have your contracting person discuss with BCBS rep.

re: new provider new patient

Per the CPT® guidelines set by AMA, and I quote: a new patient is one who has not received any professional services from the physician of the EXACT same speciat ly and subspecialty who belongs to the same GROUP PRACTICE!! NOT NPI #. I would certinley argue those guidelines with BCBS. The representives with them are not coders and they do not understand the guidelines. if that doesen't work I would let them know that you would be reporting them to the Insurance commisioner in your state. hope this helps:)

re: new provider new patient

Actually this is the definition:
A new patient 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.

You're missing the OR and it makes a difference. Contractually you might be able to argue it out with them, but from an appeals standpoint if that physician saw that patient within the last 3 years they are not going to pay it, doesn't matter what group they are with.

re: new provider new patient

I have also not seen this. Shot in the dark: you *have* added the provider and their NPI to your TIN's group contract and terminated their association with their former group(s)?

re: new provider new patient

That is correct. It makes sense. Just because the Doctor has switched practices does not mean that the patient is a new patient with that physician. If my understanding is correct. It would be as though the patient is continuing to see the physician at his new practice.

re: new provider new patient

I understand why the claim was processed as it was but how are we to know what patients our new physician seen at a former practice.

re: new provider new patient

there isn't much way of knowing, . . so then the issue becomes that of going about the billing as seems correct, then (in the case of the denial, and the reason given for it) to check in with the provider ("is this correct?"), and then either rebill as suggested (in this case, as "Established"), or assume the need for taking the case further.

re: new provider new patient

swillis - you've gotten many responses but the bottom line is, the insurance carrier goes by the provider's NPI not the group they are with. As to knowing which pts have been seen within the last 3 yrs, ask your new provider to let you know if new or est'd. They probably remember many of their own pts. If not, bill it as new but understand why you're getting the denial and submit a corrected claim. Happens all the time. Good luck