New Patient Visit Denied, What Should I Do?

Question:

One of our pain management physicians saw a patient the first time in our office. We billed 99204. The insurance carried denied the service. I contacted the insurance carrier and was told that the patient was an established patient to the practice and should be reported as an established patient. The patient did see another pain management physician in our group practice who did an injection a year ago, but it was in another city. Is the insurance carrier correct or should I appeal this?

Answer:

Since the pain management physician in the other city is part of your group and is of the same specialty with the same taxonomy code, the patient encounter for the physician in your office should be coded as an established patient visit not a new patient visit.

Per CPT Coding Guidelines: “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 theexactsame specialtyand subspecialtywho belongs to the same group practice, within the past three years.”

Since your claims was denied, it is recommended that you file a corrected claim and bill the encounter as an established patient.