Established vs new patient question

[mdo1738]

I am in an HOPD practice. There is a family medicine practice that is part of the same medical group, we’re all under the same name and under the same tax ID. They’re one of my larger referral sources. Our clinic coding is outsourced, and looking at my RVU report I have found that these coders are coding any new patient I saw who was referred by the PCPs in our group as an established patient. My understanding is that it doesn’t matter whatsoever that they’ve already been seen by the group’s PCPs, if you’re seeing a specialist for the first time, that is billed as a new patient.

Is that understanding correct? Anybody on here in a similar setup via HOPD with PCPs in the hospital system referring and it being counted as new patient? Or folks in an ortho group who are successfully billing as new patient when they’re seeing somebody sent from a surgeon in their same group? It seems so extremely obvious that this should be a new patient, but who knows with how stupid some of the rules out there are.

I feel like I saw a similar question on here a while back, but I cannot find it, sorry if this has been addressed before.

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[BobBarker]

It is a new patient. They are making a terrible error. They are probably not billing modifier 25 or any of your clinic procedures correctly either based on prior experience.

 

[Tboned]

New patient for sure

 

[callmeanesthesia]

They are not only wrong but incompetent and negligent. You should address this with your hospital admin and I wouldn’t be shy about getting a lawyer involved if you’re paid on productivity.

https://www.aapc.com/blog/41276-new-vs-established-patients-whos-new-to-you/amp/

A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

 

[gdub25]

Agree with above. You've been underpaid big time potentially. Hospital owes you money.

 

[Malayil]

What is your primary specialty?

It’s based on primary specialty.

 

[SgtThunderfistMD]

It is a new patient. They are making a terrible error. They are probably not billing modifier 25 or any of your clinic procedures correctly either based on prior experience.

Isn't that to his benefit though? If they are billing a 99214 and 20553 without using the modifiers, the RVU bean counters will give him full credit. Hospital won't get paid out of course, but that's not really his problem. And odds are it will be years until they track this back to him (honestly they probably won't care with the facility fees being the big money maker anyways).

 

[lobelsteve]

Will the doc be liable for fraudulent billing?

 

[SSdoc33]

im pretty sure the coders cant change a code you put down without your consent.

anyway, the only way this is not a "new patient" is if you are also a family practice doc.