What does a new vs. established problem mean in medical decision making (MDM)? Show A former billing auditor told me that in MDM, “new problem” means new to the provider and “established problem” means established to the provider. This means if you see a patient with a history of DM on Metformin who changed doctors and comes to see you for the first time, if you manage his DM and also refill med, that is level IV as far as the MDM section is concerned. And it can be billed as level IV if the history and physical sections are appropriate. The National Government Services, Inc, is a company that is a CMS Contracted Agent. Their Evaluation & Management Documentation Training Tool also says the same thing.  See the link below for their full training tool. Novitas Solutions on their website: “Do the terms “new” problem and “established” problem on the 1995 E&M Score Sheet under the number of diagnoses or treatment options section of the medical decision-making component mean the same as the Current Procedural Terminology (CPT) Manual’s definition of “new” vs. “established” patient? The terms “new” vs. “established” problem on the 1995 E&M Score Sheet under the number of diagnoses or treatment options section of the medical decision-making component do not mean the same as the definitions of “new” vs. “established” patient in the CPT manual. The terms on the E&M Scoresheet refer to whether or not the problem is new or established to the examiner, e.g. physician/NPP and whether or not that problem is stable/worsening or whether the physician plans to conduct additional workup on that problem or not. The CPT definitions refer to whether or not the patient is new or established to the examiner.” See CMS’s definition of a new vs. established patient. The American Academy of Child and Adolescent Psychiatry also says the same thing in their coding guide found on the acbhcs.org link below. Established problem (to examining physician); New problem (to examining physician); References E and M Training Tool from National Government Services, Inc, A CMS Contracted Agent. https://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=ab03a790-0934-4e9c-a985-9d692b4feeef Last Accessed June 2019. https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00004952 Last Accessed June 2019. http://www.acbhcs.org/providers/QA/docs/training/E_M_Doc_Training_Resources.pdf Download PDF Payment for a patient exam can vary depending on whether the patient is established or new, in which case you would get paid more. Who is considered a new patient? The Current Procedural Terminology (CPT) defines a new patient as “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.” What is a professional service? For the purpose of determining whether a patient is new or established, CPT defines professional services as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management [E&M] services reported by a specific CPT code(s).” What happens if you see an established patient but bill for a new patient? Many commercial plans would either deny the claim or, perhaps, change the CPT code from new to established. Furthermore, CMS has tasked Recovery Audit (RA) entities with identifying practices that have incorrectly used E&M or Eye visit codes that are reserved for new patients. The RA entities use data mining to identify such practices and will seek to recoup improper payments. (For more on audits, including a list of issues that auditors are targeting, see aao.org/audits.) New or Established?Q1—92228–26. Some health plans use the Healthcare Effectiveness Data and Information Set (HEDIS) to track performance. To meet a HEDIS requirement, a primary care physician (PCP) asked you to provide her with the interpretation and report of a fundus photo on a patient with known retinopathy. This patient had never been seen by you or anyone else in your group practice. You submit CPT code 92228–26 for the professional component of remote imaging for monitoring and management of active retinal disease, (e.g., diabetic retinopathy) with physician review; interpretation and report, unilateral or bilateral. That same patient now comes to see you for retinopathy. Would you bill for a new or established patient? Answer. Surprisingly, this qualifies as a new patient exam. According to CMS Transmittal 1231, “if a professional component of a previous procedure is billed in a three-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.” Q2—loyal patients follow their doctor to her new clinic. A local ophthalmologist in solo practice has now joined your group practice. Many of the patients she saw at her old clinic follow her to your clinic. Should these be billed as established patients or—since this is their first time in your clinic—new ones? Answer. If it has been less than three years since she last examined them, they should be billed as established patients. (Patients are tracked by the physician’s 10-digit National Provider Identifier.) Q3—follow-up after inpatient consult. The patient’s PCP requested a hospital inpatient consult with you. Follow-up was scheduled at your office. When the patient comes to the office for the first time, should you bill him as a new or established patient? Answer. Because of the earlier face-to-face encounter, he is an established patient. (Tip: It is wise to verify insurance participation when the patient follows up with you in the office setting.) Q4—change of TIN. A practice is acquired, and a new practice Taxpayer Identification Number (TIN) is created for it. The office location and phone numbers are the same, but the physicians who had worked there under the old TIN have all retired. None of the physicians working there under the new TIN were there before the buyout. Are patients from the acquired practice new or established? Answer. If the patients have not been examined by any of the current ophthalmologists within the past three years, they would be considered new. Congratulations to Specialist CodersFrom January 2018 through June 2019, nearly 600 physicians and staff members have passed the Ophthalmic Coding Specialist (OCS) exam and/or the OCS Retina exam, which helps to assure the coding competency of their practices. Learn more about the exams at aao.org/ocs. Q5—preexamination testing. A very busy referral cataract practice has new patients come to the office, and all testing is performed days before their actual exam with the surgeon. That way, the surgeon has all the information when making critical decisions with the patient about their upcoming surgery. Should the visit with the surgeon be billed as an exam for an established patient or—since this was the patient’s first patient face-to-face encounter with the physician—a new patient? Answer.While hospitals can have standing orders for tests, payer rules for physician office–based exams require the physician to evaluate the patient and then order any necessary testing. In this scenario, billing for a new patient exam could trigger an audit. The testing services performed prior to physician’s examination of the new patient would be considered standing orders and, as such, are not billable to the payer, only the patient. To conform with insurance billing protocol, the new patient should first be examined, and then tests that are medically necessary can be delegated. (For more on tests, see “How to Make Sure Your Billing for Tests Passes an Audit” YO Info, June 5, 2017.) What refers to whether a patient is a new or an established patient for the office?By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or ...
What is an established patient?An established patient is one who has received 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.
What is a new patient?According to CPT, a new patient is a patient who has not been seen by that physician or another physician or other qualified health care professional of the same specialty in the same group practice in the past three years.
What is a new patient quizlet?New patients are those individuals who have not received services from the physician, or an associate physician of the same group within the same specialty, within the past three years.
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