New vs. Established Patients: Three year rule
Three-year rule: The general rule to determine if a patient is new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.
Example: A patient is seen on Nov. 1, 2014. He moves away, but returns to see the provider on Nov. 2, 2017. Because it has been three years since the date of service, the provider can bill a new patient E/M code.
Billing for new patients requires three key elements and a thorough knowledge of the rules.
Billing for new patients requires a solid understanding of key elements and coding rules. A common challenge in reporting evaluation and management (E/M) services is determining whether a patient is new to the practice or already established. Since new patient codes have higher relative value units (RVUs), payers closely scrutinize these claims and often deny those that lack proper documentation.
Following the correct guidelines is essential to ensure compliance and avoid claim denials.
In an office setting, established patients are seen regularly, allowing providers to access their medical history easily. This familiarity helps in managing chronic conditions and making informed medical decisions for new concerns.
However, when a provider sees a patient for the first time, they may not have immediate knowledge of the patient’s medical background. Even if past records are available, the provider will likely need to gather more information by asking additional questions, making documentation even more critical for accurate E/M coding.
Know the Exceptions
There are some exceptions to the rules. For example, some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to her becoming pregnant. Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.
Know When to Appeal
If a claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal