I get asked this alot. (Disclaimer: I am not a lawyer, I do not provide legal advice. This post is for training purposes only. Names are fictitious, any resemblance to a real name is coincidental)
Ms Borush is a patient of Dr. George Hamilton, a doctor in Binghamton, New York. She has been seeing Dr. Hamilton for 20 years. On March 23, 2008 Mrs. Borush moves from Johnson City, NY to Albany, NY. On January 12, 2011, she moves back to Johnson City. Mrs. Borush makes an appointment with Dr. Hamilton's office for February 22, 2011. Prior to 2008, Mrs. Borush had health insurance through Empire Blue Cross from her employer, Endicott Johnson Shoes. Now Mrs. Borush is uninsured. Dr. Hamilton's office manager recommends coding this visit as a new patient simply because she is now uninsured and its been a few years since she was seen and this is a new medical condition.
When we code office visits (Evaluation and Management), when there are codes for a new patient or an established patient, we must understand the guidelines for the codes we want to select and report for payment. When you look at the CPT E/M guidelines, you see the following:
Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). 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.
An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.
No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
As you can see from the guidelines, whether a patient has insurance or not is NOT a factor when selecting a patient as new or established. Whether a patient has a new or old medical condition is NOT a factor when selecting a patient as new or established. Mrs. Borush was last seen by Dr. Hamilton in March 2008. It is February 2011, approximately 35 months since she was seen, so it is less than 3 years, since she was last seen, therefore when we look at the guidelines, Mrs. Borush is an established patient. Mrs. Borush is treated financially as an uninsured patient which means she pays for the visit out of her pocket.
If Dr. Hamilton, an internal medicine physician hired Dr. Patel, also an internal medicine physician who works with Dr. Hamilton in his office, and Mrs. Borush saw Dr. Patel, she would still be an established patient, based on the guidelines which states that An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice.
If Dr. Hamilton charges Mrs. Borush for a new patient visit, Mrs. Borush, may in hindsight do some investigating to see if she was charged correctly. If not, Dr. Hamilton may face a lawsuit or worse. If he charges an insurance company, it could open the door to a career downfall. Patients are slowly becoming smarter patients. They are double checking their medical bills. We can earn a decent living when we stay within the boundaries of published guidelines. Mrs. Borush may be a patient of Dr. Hamilton today, but that wont stop her from finding another doctor who will get her repeat business and that of her friends and neighbors.
When in doubt always refer to your coding manuals, practice compliance plans, and published rules, laws and guidelines. When I started my own computer BBS, before there was the internet, I was told by a good friend: RTFM. (Read the Fracking Manual). RTFM will always resolve office disputes or questions.