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Friday, April 2, 2010

Are you sure this patient is new?

There has long been confusion about whether to report a new or established patient visit when the physician providing the service is new to the group but has seen the patient elsewhere in the last three years or when the patient seen by Dr. A today has been seen by Dr. B of the same group at another of the group's locations.

It is more important than ever to clear up this confusion. Why? The recovery audit contractor for Medicare Region D, which covers 17 states, lists this among the issues that they are investigating. Other RACs and private payers may do the same.

It is easy for an auditor to produce a report showing new patient E/M service codes reported for a given patient. If these reports show that a patient was charged for new patient visits by the same physician or more than one physician in the same group with the same taxonomy number (specialty number) in the past three years, a request for records or, more likely, a request for a refund, may be generated.

How can you stay out of trouble?

First, make sure that everyone choosing E/M service codes in your practice understands the CPT and Medicare guidelines for reporting a new patient E/M service: Interpret “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management (E/M) service or other face-to-face service (for example, surgical procedure), from the physician or another physician of the same specialty in the group within the previous three years. Note that interpreting a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service does not affect the designation of a new patient. If a professional component of a procedure is billed but no E/M service or other face-to-face service with the patient has been performed in three years, then the patient remains a new patient for the initial visit.

Next, add a step to your pre-appointment or pre-billing process to review the patient's billing history in your practice management system and determine if any face-to-face service was billed for the patient within the past three years. If a service was provided within the past three years, determine if the patient's service must be reported as established based on the CPT and Medicare criteria.

This decision tree from FPM is a handy reference that can help you determine quickly whether the patient is new or established. Also see Emily Hill's article, which provides additional information on this topic.

Thursday, April 1, 2010

2010 Medicare physician fee schedule: Stop me if you've heard this one before

I know that it's April 1, but this is not a joke.  The U.S. Senate dropped the ball again, and Medicare payment allowances for physicians dropped 21 percent today. 

As you will recall from my last post (see "2010 Medicare physician fee schedule: What next?"), on March 2, Congress and the President enacted legislation that extended the 2009 Medicare payment rate through the end of March. This reversed a one-day drop in the fee schedule which occurred after the U.S. Senate failed to pass an extension by the previous deadline of Feb. 28, 2010. 

Like deja vu all over again (to quote Yogi Berra), the Senate again failed to pass a bill that would have extended the 2009 payment rate for physicians until April 30. The bill was ready for passage under standard unanimous consent procedures, but Sen. Tom Coburn (R-OK), playing the role previously played by Sen. Jim Bunning (R-KY), objected because the bill was not completely paid for. Then the Senate left for a two-week recess. As a result, the 21-percent reduction in physician payments took effect today.

Once again, the Centers for Medicare and Medicaid Services (CMS) is trying to play the good guy in this farce. CMS has instructed its contractors to hold claims containing services paid under the fee schedule for the first 10 business days of April, which, according to my calendar, would be through April 14. This hold will only affect claims with dates of service April 1, 2010, and forward. CMS expects the hold will have minimal impact on cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt anyway. 

The Senate will return on April 12. Senate Majority Leader Harry Reid (D-NV) has filed a motion to close debate and proceed to consideration of the temporary extenders legislation if there is no unanimous consent at that time. Expectations inside the Beltway are that negotiations between both sides will continue during the recess, and it is likely that the bill will proceed quickly through the Senate when they return. 

In the meantime, physicians are left to play the waiting game again and ponder what the punchline is. The situation might actually be funny if it weren't so sad and pathetic at the same time.

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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