ED Coding & Reimbursement Alert - 2018 Issue 1
You Be the Coder: New or Established? It's Not Simply About the Three-Year Rule
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Article Overview
This Q&A article discusses how patient status is determined for evaluation and management reporting under Medicare-oriented rules and payers that follow them. It is intended for coders, billers, and practice staff who need to understand how group practice structure, specialty and subspecialty relationships, and the three-year lookback concept affect office/outpatient E/M code selection. The article also highlights when payer-specific guidance should be verified before claims are filed.
Why This Topic Matters
Correctly identifying patient status is essential to selecting the appropriate office/outpatient E/M code family and avoiding claim errors when a patient has been seen previously in the same group practice or by a physician in the same specialty.
What You Will Learn
- How new and established patient status is discussed in the context of office and outpatient E/M services
- Why group practice and specialty relationships matter when assessing patient status
- How Medicare-oriented payer guidance can affect coding decisions
- When payer verification may be needed for borderline situations involving specialties or subspecialties
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle teams
- Physician practice managers
- Clinical documentation staff
Codes Discussed
Code Ranges Discussed
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