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March 27, 2018

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New Edit on Physician E/M Codes for New Patients

June 20, 2013:

Regina Magnani, RHIT, Clinical/Technical Editor

The Centers for Medicare and Medicaid Services’ recovery audit contractor (RAC) program has identified improper fee-for-service payments under Medicare for claims incorrectly reported with “new patient" evaluation and management (E/M) services that should have been reported with “established patient” E/M codes.

The Medicare Claims Processing Manual, Pub. 100-4, chapter 12, section 30.6.7, defines a new patient as a patient who has not received any professional services—E/M services or other face-to-face services—from the physician or physician group practice (same physician specialty) within the previous three years. A diagnostic test interpretation in the absence of an E/M or other face-to-face service with the patient does not affect the new patient status. For example, if someone’s lab result was interpreted by a physician within the last three years, that person would still be considered a new patient for the initial visit to that physician if no E/M or face-to-face service had been performed within that same time frame.

The American Medical Association’s guidelines for its E/M CPT® codes define a new patient as one who has not received any professional services from the same physician or another physician of the same specialty and same group practice within the past three years.

Using the CMS definition of new patient, RACs found significant overpayments for erroneous new patient E/M codes when established patient E/M codes would have been correct. As a result of these overpayments, the CMS Common Working File (CWF) will verify that two new patient CPT codes are not paid to the same physician or physician group within a three-year period effective October 1, 2013. If in the last three years, the earliest claim has an established patient E/M code, the current claim for the new patient code will be rejected.

Note that facilities define new patient differently under the hospital outpatient prospective payment system. An established patient was registered as an inpatient or outpatient of the hospital within the past three years. As with past policy, the same patient could be new to the physician but an established patient to the hospital, or an established patient to the physician and new patient to the hospital.


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