what specialties does medicare recognize for new patient

Background: The CMS

Recovery Audit Contractor (RAC) program is responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The contractor claim data identified claims with "New Patient" Evaluation and Management (E&M) services that have improper payments. Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.7 provides that “Medicare interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M 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 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.” As a result of overpayment for new patient Evaluation and Management services that should have been paid as established patient Evaluation and Management services, CMS will implement an Informational Unsolicited Response (IUR) from the Common Working File (CWF) to prompt the system to validate that there are not two new patient CPTs being paid within a three year period of time.

Full Answer

What kind of doctors are covered by Medicare?

A doctor can be one of these: Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) In some cases, a dentist, podiatrist (foot doctor), optometrist (eye doctor), or chiropractor. Medicare also covers services provided by other health care providers, like these: Physician assistants. Nurse practitioners.

What services does Medicare pay for in a hospital?

doctor services (including outpatient services and some doctor services you get when you’re a hospital inpatient) and covered preventive services. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges.

How do I know what specialty a physician is registered under?

For Medicare patients, you can use the National Provider Identifier (NPI) registry to see what specialty the physician’s taxonomy is registered under. For payers, this usually is determined by the way the provider was credentialed.

Does Medicare pay for a gynecologist with a different specialty?

So, if we’re reporting to Medicare, and if we assume the gynecologist obstetrician is appropriately designated, they will meet the requirement of “different subspecialty” (for Medicare patients, you can use the National Provider Identifier (NPI) registry to see which specialty the physician’s taxonomy is registered under).

What is Medicare Administrative Contractor?

What is RAC in Medicare?

About this website

What does CMS consider a new patient?

New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years.

Does Medicare pay for new patient visits?

Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.

Why are you considered a new patient after 3 years?

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 does a new patient visit consist of?

Definition and Overview The exam involves an in-depth check of the patient's medical history, comprehensive exams on specific parts of the body where the symptoms originate from, as well as x-rays and other imaging scans. This exam can help detect any diseases that the patient may have.

What will Medicare not pay for?

In general, Original Medicare does not cover: Long-term care (such as extended nursing home stays or custodial care) Hearing aids. Most vision care, notably eyeglasses and contacts. Most dental care, notably dentures.

What is the difference between Welcome to Medicare and Annual Wellness Visit?

Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit. Medicare Part B covers the Annual Wellness Visit if: You have had Part B for over 12 months.

What does New patient qualifications not met mean?

“A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician /qualified healthcare professional of the exact same specialty and subspecialty WHO BELONGS TO THE SAME GROUP PRACTICE, within the past three years.”

How long before an established patient becomes a new patient?

three yearsBy 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 the difference between 99213 and 99203?

99203 combines the presenting problem (and decision making) of 99213 with the history and physical of 99214. All require four HPI elements except 99213.

What should I ask at a new patient appointment?

Talking to Your Doctor: 7 Things to Cover at a New Patient VisitYour Relevant Medical Information. ... Your Family Medical History. ... Current Medications. ... New Symptoms. ... Cultural/Personal Preferences. ... Your Lifestyle. ... Home/Work Situation.

What do doctors do on first visit?

Be prepared for your first visit to your new doctor. That's because your doctor will ask you about your “medical history” and “family health history” to get a clear picture of you and your health. Before your well-woman visit, spend some time learning your family's health history.

What do you say to a new doctor?

Here are some good starter questions you can ask your doctor:What do my symptoms mean?Should I be tested for a disease or condition?What caused this condition?How serious is the condition?How is it treated?Are there any side effects to the treatment?How long will treatment take?More items...•

CPT code – 99201, 99202, 99203, 99204 – 99205 – office visit code ...

CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the ...

Evaluation and Management Services Guide Booklet

Evaluation and Management Services Guide. MLN ooklet Page 4 of 23. MLN006764 February 2021. GENERAL PRINCIPLES OF E/M DOCUMENTATION. Clear and concise medical record documentation is critical to providing patients with quality care and is

Place of Service Code Set | CMS

Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes.

Different Specialties, Same Tax ID - KarenZupko&Associates, Inc.

August 13, 2015. Question: Can you help clarify the new patient rules related to multiple specialties in the same group practice? If we have different specialties (e.g., Pain Management, Podiatry, Rheumatology, Orthopaedics) can we charge a New Visit code when the patient is seen for the first time by a physician in a different specialty in the practice?

2021 Consultation Codes Update | CPT codes 99241-99245, 99251-

Consultation Codes Update, June 2022: The May 2022 CPT Assistant announced there are changes coming to E/M codes in 2023, including consultations.

Evaluation and Management (E/M) Code Changes 2021 - AAPC

99203 : Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity.Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and ...

Does EKG affect new patient designation?

An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (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.

Is Dr Smith still at Clinic A?

Although, Dr. Smith is no longer at " Clinic A," the patient is still considered an established patient for Dr. Jones as Dr. Smith and Dr. Jones are of the same specialty.

What is a doctor in Medicare?

A doctor can be one of these: Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) In some cases, a dentist, podiatrist (foot doctor), optometrist (eye doctor), or chiropractor. Medicare also covers services provided by other health care providers, like these: Physician assistants. Nurse practitioners.

What is original Medicare?

Your costs in Original Medicare. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. for most services.

What is Medicare assignment?

assignment. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. . The Part B. deductible.

What does "covered" mean in medical terms?

medically necessary. Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

What is the goal of a medical specialist?

Every medical specialist shares one common goal: to help patients get healthy or stay healthy. But each one has very specific skills and competencies that make them an integral member of the medical field. Learn more about each specialty and the subspecialties that fall underneath them.

What is the specialty of neurology?

Neurology. Neurology is the specialty within the medical field pertaining to nerves and the nervous system. Neurologists diagnose and treat diseases of the brain, spinal cord, peripheral nerves, muscles, autonomic nervous system, and blood vessels.

What is emergency medicine?

Physicians specializing in emergency medicine provide care for adult and pediatric patients in emergency situations. These specialists provide immediate decision making and action to save lives and prevent further injury. They help patients in the pre-hospital setting by directing emergency medical technicians and assisting patients once they arrive in the emergency department.#N#Emergency medicine is also home to several subspecialties, including the following:#N#• Anesthesiology critical care medicine#N#• Emergency medical services#N#• Hospice and palliative medicine#N#• Internal medicine / Critical care medicine#N#• Medical toxicology#N#• Pain medicine#N#• Pediatric emergency medicine#N#• Sports medicine#N#• Undersea and hyperbaric medicine

What is the branch of medicine dedicated to pain relief for patients before, during, and after surgery?

Anesthesiology . Anesthesiology is the branch of medicine dedicated to pain relief for patients before, during, and after surgery. The American Board of Anesthesiology outlines the following subspecialties within the field in the following areas of care: • Critical care medicine.

What is the specialty of allergy and immunology?

Specialists in allergy and immunology work with both adult and pediatric patients suffering from allergies and diseases of the respiratory tract or immune system. They may help patients suffering from common diseases such as asthma, food and drug allergies, immune deficiencies, and diseases of the lung.

What is the medical term for treating the skin?

3. Dermatology. Dermatologists are physicians who treat adult and pediatric patients with disorders of the skin, hair, nails, and adjacent mucous membranes. They diagnose everything from skin cancer, tumors, inflammatory diseases of the skin, and infectious diseases.

What is pediatrics?

Physicians specializing in pediatrics work to diagnose and treat patients from infancy through adolescence. Pediatricians practice preventative medicine and also diagnose common childhood diseases, such as asthma, allergies, and croup.

What is a new patient?

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.

Why do internists bill established patient codes?

The internist must bill an established patient code because that is what the family practice doctor would have billed.

How to check if a new patient is denied?

If a new patient claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal.

How long does it take to determine if a patient is new?

Three-year rule: The general rule to determine if a patient is “new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.

What does a provider know about a patient's history?

The provider knows (or can quickly obtain from the medical record) the patient’s history to manage their chronic conditions, as well as make medical decisions on new problems. A provider seeing a new patient may not have the benefit of knowing the patient’s history.

Why are doctors forbidden to tell patients where they are going?

Due to established covenants not to compete, most physicians in this area are forbidden by written contract to tell their patients WHERE they are going. If a former patient shows up at the new practice, they are establishing care with the new practice as a new patient.

Do all E/M codes fall under the new vs. established categories?

Not all E/M codes fall under the new vs. established categories. For example, in the emergency department (ED), the patient is always new and the provider is always expected to get the patient’s history to diagnose a problem.#N#In the office setting, patients see their provider routinely. The provider knows (or can quickly obtain from the medical record) the patient’s history to manage their chronic conditions, as well as make medical decisions on new problems.#N#A provider seeing a new patient may not have the benefit of knowing the patient’s history. Even if the provider can access the patient’s medical record, they will probably ask more questions.

How many visits can a new patient have with the same provider?

Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period. This guideline is outlined in the Internet Only Manual, Publication 100-04 Chapter 12 Section 30.6.7A.

What is CMS CR 8165?

As previously announced with notification of CMS CR 8165 ( MM8165) Medicare implemented a common working file system edit to identify claims where more than one new patient visit was billed for the same patient within three years.

Can I change my new patient visit to an established patient visit?

Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit? Yes, if the service you actually performed was an established patient visit you can request a telephone reopening by calling 1-877-735-8073 for Jurisdiction L or 1-855-252-8782 for Jurisdiction H.

Does Medicare allow a new patient visit?

Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider. Note: Providers are encouraged to contact our telephone reopening line timely as recoupment action will occur. If you do not have reason to appeal/request a telephone reopening and are in receipt ...

What is a new patient?

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.

What chapter of Medicare defines a group practice?

One must also know how to define a group practice to interpret the new and established patient rules. Medicare has defined a group practice in Chapter 5 of Medicare General Information, Eligibility, and Entitlement. Section 90.4 (pdf page 38) says:

How should a physician or NPP code patients after they have left one group practice and joined another?

How should a physician or NPP code patients after they have left one group practice and joined another? Under a new group or solo practice, the physician would have a new tax identification number. However, the definition of a new patient says they cannot have received professional services in the last three years from the physician or qualified healthcare professional. Some payer algorithms may not be able to identify the new vs. established patient decision for physicians or NPP who change tax identifications. Some may. To bill and code correctly the correct interpretation of this scenario says to bill established patient care codes if the physician or NPP has seen the patient for professional services in the last three years.

What is a CPT professional service?

The 2018 CPT® manual defines professional services as those face-to-face services provided by physicians or other qualified health care professionals who may report an E/M service by a specific CPT® code.

What is the code for a consult request?

If consultation codes are allowed by the patient's insurance company, then code group 99241-99245 should be used for the consult request.

What is a qualified non-physician practitioner?

Qualified non-physician practitioners are considered part of the group practice and specialty for which they provide service along with physicians in the same specialty and group practice. In fact, Medicare's E/M Services Guide (on page 7 linked above) states quite clearly that non-physician practitioners are treated the same as physicians as providers of professional services over the three year time frame. Even the CPT® definition bundles the physician with qualified health care professional in their definition of new vs. established patients. In addition, the 2014 CPT® manual says

What is a group practice?

A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:

What is Medicare Administrative Contractor?

The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

What is RAC in Medicare?

Background: The CMS Recovery Audit Contractor (RAC) program is responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The contractor claim data identified claims with "New Patient" Evaluation and Management (E&M) services that have improper payments. Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.7 provides that “Medicare interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M 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 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.” As a result of overpayment for new patient Evaluation and Management services that should have been paid as established patient Evaluation and Management services, CMS will implement an Informational Unsolicited Response (IUR) from the Common Working File (CWF) to prompt the system to validate that there are not two new patient CPTs being paid within a three year period of time.