Physician Practice

Q&A: You've got questions! We've got answers!

Physician Practice Insider, October 2, 2017

Question: We have multiple practice locations, and I have a couple of questions about the new-versus-established patient rules for E/M visits. Each of our practices has a unique group national provider identifier (NPI), but they share a tax identification number (TIN).

The first question is: What happens when a patient leaves one practice, goes to a different practice and sees a new doctor of the same specialty? Is the patient new or established for his first visit with the new doctor at the new practice?

The second question is about what happens when a doctor leaves one of our locations and goes to work at another of our offices. A patient follows the doctor, but on her first visit, she is seen by another doctor of the same specialty. Is that patient new or established?

In both cases, the patients are seen within the three-year period.

Answer: The shared TIN is enough to create the established patient status for the purposes of billing E/M outpatient office visits. The visits would be reported with the appropriate established patient code (99211-99215).

For the second scenario, it is important to note that the visit would be established even if the patient had followed a doctor who is new to the group — for example, if the doctor had closed her single-provider practice and come to work for your group.

Those questions emphasize the fact that a patient’s established status is a highly contagious, long-lasting condition. Once a physician has face-to-face contact with a patient, the established status applies to that physician and everyone in her group who is of the same specialty. Each face-to-face encounter restarts the three-year clock.

Practices should be aware that prosecutors and other enforcement officials are becoming very aggressive about new-versus-established billing mistakes. Since June, three health systems have agreed to pay a total of $877,221.36 to settle allegations that they violated the False Claims Act by improperly billing established patients as new patients.

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