New vs Established patient

[yoloswagpoop42069]

I know for CMS established patients are ones that someone in your practice has seen in the last 3 years.

So you can’t rebill 99205/99204 etc.

But is this the same for all private insurances as well, or do they define established patients on a different time line?

Like hasn’t been seen in 180 days? Hasn’t been seen in like 1 year and not on meds for the year can be billed as a new pt 99204?

My colleague was saying for privately insured patients who have not been seen in 1 year and have not been on meds can be billed as new and that CMS criteria is different than private insurances.

But I can’t find any sources on this.

Also my new job just emailed saying patients who haven’t been seen in 180 days as an outpatient need to go through the “new patient” establishment process, although they didn’t specify billing.

So I figured I’d ask here instead.

****ing noob questions that should have easy answers.

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[ObsequiousAplomb]

Whether or not you can't bill a 99204/99205, you can still bill the people who need to be treated as new despite not being new as a 90792 or 99214+90836 or 99214+90838, provided you structure the visit to include those services. All three of those options would pay more than 99204 and some of them might pay more than 99205.

 

[yoloswagpoop42069]

Whether or not you can't bill a 99204/99205, you can still bill the people who need to be treated as new despite not being new as a 90792 or 99214+90836 or 99214+90838, provided you structure the visit to include those services. All three of those options would pay more than 99204 and some of them might pay more than 99205.

Absolutely I understand.

I just wanted to know what the rule for sure for 99204/99205s was though for insurances.

My outpatient practice is a little strange in that we can’t bill outpatient add on therapy codes.

90792s vs typical 99204/99205 I’m not sure of. I can try to look this up again, I’m still not sure what the differences are.

 

[splik]

Absolutely I understand.

I just wanted to know what the rule for sure for 99204/99205s was though for insurances.

My outpatient practice is a little strange in that we can’t bill outpatient add on therapy codes.

90792s vs typical 99204/99205 I’m not sure of. I can try to look this up again, I’m still not sure what the differences are.

Private insurances follow CMS guidance. So yes, cannot used new E&M codes if seen by you or any psychiatrist in your practice in the past 3 yrs. However you can use 90792.

 

[yoloswagpoop42069]

Private insurances follow CMS guidance. So yes, cannot used new E&M codes if seen by you or any psychiatrist in your practice in the past 3 yrs. However you can use 90792.

Perfect thank you!!!!

It blows my mind, I just started working because I graduated residency off cycle, but asked two colleagues of mine who have been working longer than I have and they both said new patients are just after 1 year of not being seen.

I don’t know why clinics perpetuate incorrect billing information… do they try to just get away with it because they won’t get caught after 1 year?

I will look up the differences between 90792 vs 99205/4/3 especially as there has been some threads in SDN about it, but if someone is able to easily clarify differences I would appreciate it. If not I’ll hit google.

Is it just not a big deal to bill 99204s after 1 year?

Are there any limits to frequencies for 90792s?

 

[yoloswagpoop42069]

I’ve found online and other sources:

“90792 is not subject to the 3 year rule as for example the 99211-99215 are. The diagnostic interview exam is done when the provider first sees a patient, but may also be utilized again for a new episode of illness, or for re-admission as an inpatient due to underlying complications.”

For others who are curious

 

[Sushirolls]

You have such an artisan username. Do tell, what creative process helped you pick it?

 

[yoloswagpoop42069]

You have such an artisan username. Do tell, what creative process helped you pick it?

It’s the name of my outpatient cash only private practice.

I appreciate you man, you’re the GOAT.