New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices

What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:

The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

*This response is based on the best information available as of 08/25/22.

E/M Visit During the Global Period

Question:

Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure?

Answer:

Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated to the original procedure and reflect a clear plan of treatment for the new/unrelated issue. You will then append modifier 24 (unrelated E/M in a global period) to the E/M code.

*This response is based on the best information available as of 08/11/22.

2021 Evaluation and Management Codes: Is a History Required?

Question:

My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.

Answer:

You are wise to ask because that’s not exactly true. It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that you will document a “medically appropriate” (per CPT™ history for each encounter.

*This response is based on the best information available as of 07/28/22.

Modifiers on Unlisted Codes. Yes or No?

Question:

Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code.

Answer:

There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers are not appended to an unlisted code.

Payors have their own rules. For example, some payors will accept modifier 62 (two surgeons/co-surgery) on an unlisted code such as 64999 while other payors do not.

We would not append modifier 50 (bilateral procedure) to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

We also would not append modifier 51 (multiple procedures) to an unlisted code. Let the payor take the discount.

*This response is based on the best information available as of 07/14/22.

Confusion Regarding the 2021 E/M Guidelines

Question:

The guidelines that came out in 2021 for E/M services is for all types of E/M services, right?

Answer:

No. The 2021 E/M guidelines are for office/outpatient visit codes only (99202-99215). You will still need to use the 1995/1997 guidelines for all other E/M services, even consultations in the office.

*This response is based on the best information available as of 06/30/22.

Incident-to Requirements for Medicare

Question:

Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare.

One of my physicians is stating that her attorney told her being “under the same roof” of the building counts and you don’t necessarily need to be in the same suite. I am disagreeing stating they have to be in the same suite and even though she is available to run upstairs if needed, by her being on the second floor that goes against the “incident-to” rules. Am I correct?

Answer:

According to CMS In order to qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service. Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the supervising physician must be present in the room where the procedure is performed. Also the supervising physician must be immediately available (without delay). The supervising physician can be in another room As long as they are not performing a procedure that they cannot stop and go to help with the other patient then they are considered immediately available. CMS also clarifies that immediately available

CMS has clarified the office suite it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner.

Sources:https://med.noridianmedicare.com/web/jeb/topics/incident-to-servicesand CMS Medicare Benefit Policy Manual Pub. 100-2, Section 60https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

*This response is based on the best information available as of 06/16/22.