FW: New vs Est for Advanced Practitioners

I am looking for a reliable source document on the below issue. I found this below and now I cannot seem to find it. My problem is the physicians are challenging me on this. Here is my example..

Patient seen the PA last year for their foot, today come in and see the Ortho physician. He feels he can bill a new patient because he is of a different specialty. I have been taught there is no subspecialty for the Adv. Pract. And that physician would have to bill an est pt because the patient has been here with in the 3 year rule. Do you agree???

The subspecialty comes in when a general ortho physician see the patient for their foot and then come in today to see the hand surgeorn. Because the hand surgeon is of a different specialty he can bill a new pt. right?

HELP!!!!!!!!!!!!!!!!!!!!!!!!!!!!


NPP Visit Affects "New vs. Established" Status

If a non-physician practitioner (NPP)-but not a physician-has seen a patient within the last three years, is the patient new or established?

Although CPT(r) consistently uses the term "physician" in the context of the determining whether a patient should be considered "new" or "established," most payers-Medicare payers in particular-don't apply that instruction literally. For example, Medicare's definition of a new patient, taken from the Medicare Carriers Manual, instructs:

"Interpret the phrase 'new patient' to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years" [emphasis added.]

Because the NPP would be a member of the group practice, if he or she has seen a patient within the past three years, that patient would be established with the group.

The Centers for Medicare & Medicaid Services (CMS) offers even more explicit instructions in its MLN Evaluation and Management Services Guide:

"For purposes of billing for E/M 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.

"An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years" [emphasis added].

The bottom line: If the patient has seen an NPP in the practice within the previous three years, you should treat the patient as established. *NPP's are not specialty specific.
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