RE: PRIOR PATIENT NOT SEEN IN 3 YRS

Hi
I need feedback please
Patient has/had a workcomp case and hadn't been in to see the physician in 3 years. The same MD as she saw for the last visit, so established to the MD and established problem. She came in and the HPI states hasn't been in for such and such time and her condition is that of the same as the last time she was in, The HPI says intermittent pain controlled with NSAID and sometimes give her pain with overhead movements etc. I coded this to 99202 (due to the three year gap) but under the MDM I coded as established problem to examiner. I went with 99202 both on SF MDM (the doctor indicated her MSD was stable) he didn't' say reinjured or anything else that was substantial. He also had a time statement saying that he spent 15,min with the patient and 10 min of that time was spent counseling on MSD disorder how to prevent flare ups etc etc.. so 99202 was my choice, I am being advised that it should have been 99203 because the problem is considered new to the examiner, I say this is WRONG!
Any one else...

Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
AHIMA ICD10 PROFICIENT
Government Reimbursement Analyst-Sharp Health Care
PFS-CCD 3rd Floor
858-499-4382


Comments

  • The CPT book under E&M guidelines has a decision tree for new vs established patients. 1. Received any professional service from the physician or another physician in group of same specialty within the past three years? No=New patient.


    Vickie Trotter, CPC
    Corporate Auditing
    vickie.trotter@infirmaryhealth.org
    Phone: (251) 435-3917
    Fax: (251) 435-7246

  • I think most of the carriers in the country follow Medicare's rule about the 3 years since last professional face-to-face service for the distinction of new or established patients - but be aware that not all do. For instance, it is either North Carolina or South Carolina or both that says if it's a new injury - it's a new patient. You might want to check with each of your own carriers to make sure. But the vast majority of the major carriers do follow the 3 year rule.


    Don
    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    books & webinars at https://shop.donself.com

  • Right, I understand the 3 year rule, that’s not the issue, the issue is regardless, it’s a known problem to the examiner, I did grant it as new patient, but to 99202 not 99203 because I logged the problem as established to the examiner, which it was. This is an established work comp patient, just following up for protocol is how I saw it.

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382



  • You may want to check with your state's Industrial Commission/Worker's
    Compensation office. In Arizona, we can code a New Patient visit for
    services provided to an established patient and bill it to the WC carrier.
    In fact, if the patient has multiple Worker's Compensation injuries, each
    separate injury gets charged with a New Patient code on the first visit
    dealing with that specific injury. It goes against all coding guidelines
    and I think it is crazy, but these are our rules!

    Charlene Endre-Burgett, MS-HCM, CMA (AAMA), CPC, CMCS, CHM, CPOM
    Chief Operating Officer
    North Scottsdale Family Medicine
    LinkedIn: www.linkedin.com/in/charleneburgett



  • edited May 2017
    Karyn-
    I would agree with your thinking. New patient but old problem unless there was something indicating something was different for this problem.

  • Exactly. It's an established problem I thought with a successful treatment plan for the most part how can it be new. It appears she was just following up for protocol most likely still an open case. I have an issue with using HEM when there is a clear time statement documented for a lower level! I mean I think then the time statement should be amended out of the record

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

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