decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
New vs Established Patients / CMS cracks down on new patient claims
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Article Overview
This article discusses Medicare's focus on new patient evaluation and management claims and why practices may receive requests to validate those encounters. It is aimed at coders, billers, compliance staff, and providers who need to understand how specialty registration, group practice structure, and documentation standards affect new versus established patient status. The article covers the general circumstances that can trigger payer review, the role of Medicare guidance, and the documentation areas that often draw attention.
Why This Topic Matters
New patient claims are often higher paid and therefore subject to closer payer review. Understanding the Medicare framework and documentation expectations can help practices respond appropriately to carrier inquiries and reduce the risk of repayments or denials.
Article Sections
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Medicare scrutiny of new patient claims
Introduces payer review of new patient evaluation and management services and the reasons practices may be asked to validate billed encounters. It frames the broader compliance concerns involved in these claims.
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New patient status and specialty distinctions
Explains how Medicare’s general framework for determining whether a patient is considered new can be affected by time interval and physician specialty within a group practice. The section focuses on how specialty registration and multi-specialty settings can influence claim review.
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Example of a carrier review scenario
Presents a broad scenario illustrating how claims from different providers in the same practice may be reviewed when new patient visits appear within a limited timeframe. The discussion remains centered on documentation and validation concerns.
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Documentation expectations for new patient visits
Summarizes the documentation emphasis for new patient evaluation and management services, including the need to support the required components of the visit. It also highlights the history-taking element as a common area of vulnerability.
What You Will Learn
- How Medicare scrutiny can affect new patient evaluation and management claims.
- Why specialty designation within a group practice matters when claims are reviewed.
- What broad documentation areas are expected for new patient visits.
- Which parts of the visit are commonly examined during payer review.
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Physicians and other providers
- Practice managers
Codes Discussed
Code Ranges Discussed
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