Ask the Expert

This month’s selection:
My facility has a physician who also practices as a radiation oncologist and sees patients part time at the local wound care center. There are several physicians from my facility who work part-time at the wound care center and focus on different specialties (eg, family practice, general surgery, radiation oncology).

The radiation oncology provider has asked whether it is appropriate to bill a new patient visit if she sees a patient at the wound care center whom she doesn’t know but is a “frequent flyer” at the center. In other words, other providers at the wound care center have seen the patient, and all of them are acting in the same capacity.

Is it ethical to bill a new patient visit in such a scenario? It seems a little questionable based on the same service the physicians are all providing to the wound care patients. However, the Centers for Medicare & Medicaid Services (CMS) does state it is acceptable to do this if the providers have different specialties.

I should add that each provider does their own billing for the wound care center; they are not part of a group.

Cristy Donaldson, CPC, CPMA
Coding Manager
Knoxville, Tennessee

 

Response:
A key to differentiating between new and established patients is understanding the terms used in the CPTs and CMS definitions of a new patient, including “group practice.”

By CPT definition, 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.”

CMS guidance states, “For purposes of billing for E/M [evaluation and management] services, patients are identified as either new or established, depending on previous encounters with the provider. A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.”

Medicare views physicians within the same group with the same specialty as the same person. A group is comprised of members having the same tax identification number. If there are different tax identification numbers, the physicians are not part of the same group for Medicare billing.

In the scenario provided, the patient had not received prior professional services from the provider, and the provider is not part of a group that had previously treated the patient. Therefore, I would assign a new patient visit per the coding and billing guidelines.

— Jane Wehr, RHIA, CCS, CCS-P, is the national compliance manager for Kforce Healthcare.