Distinguishing a New from an Established Patient
When you look at the CPT E/M guidelines you see the following: 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.
Whether a patient has a new or old medical condition is NOT a factor when selecting a patient as new or established
and 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
Following Compliance Plans
You might send a claim to ABC insurance and XYZ insurance. XYZ may deny payment stating that the primary paid
more than what they would have paid. If you look at the patient's Summary Plan Description (SPD) or Health Benefit
Manual, you may see that XYZ is required to pay what ABC didn't pay. XYZ insurance may only be required to pay 40%
of their allowed amount with the patient having to pay the 60% of the allowed amount, including any and all amounts
of the balance of the providers charges. You may be interacting with a patient with Medicare and Veteran
Administration (VA) retired military benefits. Learn what is required when this happens.
As a medical biller you have to be on top of all of the ins and outs that accompanies medical and health
insurance claims and you have to be 100% correct all of the time. You also have to be in compliance with the
doctor's contract, applicable state and federal laws and ensure patient compliance with their insurance company
rules and contracts they or their employer signed. If you have employees, ensure they are properly trained and they
undergo follow-up training to stay current and in compliance.
The answers to anyone's question is out there. Although this is the microwave generation who is accustomed to
things available instantly, one must have patience when looking for answers to such complex rules and regulations
that revolve around health insurance coverage, policies and regulations.
Medical Coding Questions
Your answers can be found by opening and reading the CPT. ICD-10-CM or HCPCS Manual. These books not only contain
the codes and modifiers we use, they also contain the guidelines behind coding. Training can teach you how to use
these books properly and how to find a code you need.
The answers are in many locations. The claim form information can be found on the NUCC website and via health insurance claims policies. Submission time frames can be
- provider contracts
- State insurance laws or
- the patient benefit manual or summary plan description.
Health insurance websites can be a cornucopia of information. If you research a certain website and find a
policy or manual then save it for later reference and return for more information.
Sometimes, you might hear, is it legal to.....? Or, what you are doing is illegal!!! Unless you are a lawyer, or
in law enforcement you can't say something is legal or illegal. In my many years of research, I have yet to find
one state that has medical billing laws. What I have found are laws that regulate insurance (Health, Workers
Compensation and Auto Accident (PIP Coverage). Some laws are not easy to find and one has to read the law carefully
because they can be very "lawyerly" in language. Legal interpretation of the lingo is up to the lawyers.
The Internet is chock full of valuable information. The search engine one uses is up to the individual person
and their preference. I prefer Google. How someone asks a question depends on what kind of answer will be found. I
can google the question and 99% of the time I will find an answer but to verify it, I must go back to the books and
apply what I have learned in my role as a qualified medical biller.
REMEMBER: When in doubt always refer to your coding manuals, practice compliance plans, and published rules,
laws and guidelines. When you research on your own, you become a much better person. You learn where to find the
answers. You can become the medical billing superstar you want to be.
from entries in Our
Medical Billing Community forum.
Reprinted with permission from the
author, Steve Verno, Certified Medical Biller)