decisionhealth Newsletters, Part B News - 2012 Issue 7 (July)
Review new vs. established rules to avoid CMS scrutiny, downcodes
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Article Overview
This article reviews outpatient evaluation and management billing guidance for distinguishing new and established patients. It is aimed at coders, billers, compliance staff, and clinicians who want to reduce claim errors, avoid payer scrutiny, and understand how specialty, timing, and practice relationships affect patient status. The discussion covers general billing rules, common multi-practice scenarios, and examples of how patient status can change across encounters.
Why This Topic Matters
Incorrectly classifying patient status can affect payment accuracy and may increase the risk of denials, downcoding, or payer review. Understanding the broad rules helps practices support compliant billing and avoid avoidable revenue loss.
What You Will Learn
- How outpatient patient status is generally distinguished between new and established visits
- Why Medicare scrutiny makes correct patient classification important
- How timing and specialty relationships can affect billing classification
- How multi-specialty and multi-practice scenarios are discussed in relation to patient status
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Physicians and practice managers
Codes Discussed
Code Ranges Discussed
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