RE: billing new/established after move

January 7, 2006

I had been told the same thing, but when I started my own practice, the

consultant and the billing company both insisted that EVERY patient was

a new patient the first time they came to my NEW practice and got billed

under my new billing numbers. That was in 7/02 and all claims were

paid as new patients with no fuss from insurers.

Annie

-----Original Message-----

There's an article in FPM about coding new vs established and if you've

seen

them in any capacity, even completely different facility, not your old

one,

in the past 3 years, they are established. I can try to dig up the link

for

you if need me to.

Lynn

>But this reminds me of something I meant to ask previously. For those

of

>us setting up shop near our old offices, when patients of the prior

office

>switch and are seen in the new site, is the billing for a new patient

or

>for an estabished patient?

>

January 7, 2006

Lynn and Annie - thanks. What you both say matches things I've casually

heard in the past. That is, the issue is confusing! I can see the logic

in both sides of the argument -- that a patient has been seen by me, thus

is not " new " BUT considering the concept of new patients involving extra

work administratively and in organizing old records I can imagine billing

as " new " still I'll still have the extra work as part of the care.

For 8 years it's been a hassle to have an essentially new patient

transferring internally (with record transferred from another facility in

our system) and only being able to bill as " established " ... emotionally I

feel like insurance should cut me a break after getting away from that.

But, of course, insurers don't have emotions, do they! ;-)

Anyone actually have claims denied or downcoded after they billed as new

for a patient transferring from a prior office?

Tim

> I had been told the same thing, but when I started my own practice, the

> consultant and the billing company both insisted that EVERY patient was

> a new patient the first time they came to my NEW practice and got billed

> under my new billing numbers. That was in 7/02 and all claims were

> paid as new patients with no fuss from insurers.

> Annie

>

> -----Original Message-----

>

January 7, 2006

I think an ethically sound argument to go either way on this issue.

Maybe the way ahead is to ask a major insurer to weigh in? This way

if you do bill as new for the burden of administrative work and are later

challenged, you could cite their own advice.

Gordon

At 08:33 AM 1/7/2006, you wrote:

Lynn and Annie - thanks.

What you both say matches things I've casually

heard in the past. That is, the issue is confusing! I can see the

logic

in both sides of the argument -- that a patient has been seen by me,

thus

is not " new " BUT considering the concept of new patients

involving extra

work administratively and in organizing old records I can imagine

billing

as " new " still I'll still have the extra work as part of the

care.

For 8 years it's been a hassle to have an essentially new patient

transferring internally (with record transferred from another facility

in

our system) and only being able to bill as " established " ...

emotionally I

feel like insurance should cut me a break after getting away from

that.

But, of course, insurers don't have emotions, do they! ;-)

Anyone actually have claims denied or downcoded after they billed as

new

for a patient transferring from a prior office?

Tim

> I had been told the same thing, but when I started my own practice,

the

> consultant and the billing company both insisted that EVERY patient

was

> a new patient the first time they came to my NEW practice and got

billed

> under my new billing numbers. That was in 7/02 and all

claims were

> paid as new patients with no fuss from insurers.

> Annie

>

> -----Original Message-----

>

January 7, 2006

I don't have our fee schedule at home to clarify, but has anyone considered that USUALLY, you can bill a higher E & M level for an established pt with same problems than for a new one, because you only need 2 of 3 components, with the exam often being a limiting factor with new pts. Just asking-what is the difference in the fee, for instance, for 99214 vs. 99203? I looked into this before because I was "irate" that I was seeing a lot of patients transferring from another office in our ambulatory system, and I was told I had to code as an established pt. because the system all had the same Tax ID # so they were established with the system. When I checked into the difference, realizing usually you can use the higher E & M level, it was not that much different, but I can't recall the details in dollars.

Just a thought.

RE: billing new/established after move

I think an ethically sound argument to go either way on this issue. Maybe the way ahead is to ask a major insurer to weigh in? This way if you do bill as new for the burden of administrative work and are later challenged, you could cite their own advice.GordonAt 08:33 AM 1/7/2006, you wrote:

Lynn and Annie - thanks. What you both say matches things I've casuallyheard in the past. That is, the issue is confusing! I can see the logicin both sides of the argument -- that a patient has been seen by me, thusis not "new" BUT considering the concept of new patients involving extrawork administratively and in organizing old records I can imagine billingas "new" still I'll still have the extra work as part of the care.For 8 years it's been a hassle to have an essentially new patienttransferring internally (with record transferred from another facility inour system) and only being able to bill as "established" ... emotionally Ifeel like insurance should cut me a break after getting away from that.But, of course, insurers don't have emotions, do they! ;-)Anyone actually have claims denied or downcoded after they billed as newfor a patient transferring from a prior office?Tim> I had been told the same thing, but when I started my own practice, the> consultant and the billing company both insisted that EVERY patient was> a new patient the first time they came to my NEW practice and got billed> under my new billing numbers. That was in 7/02 and all claims were> paid as new patients with no fuss from insurers.> Annie>> -----Original Message----->>>>>

January 7, 2006

RE Billing as new pt

I remember that Family Practice Management Q & A did do some review of this.

You could try (open website ref) at aafp.org/fpm

But I've been in similar situation as a family practice doc (now 1.5 years

away from my " former " hospital owned practice, still running with

substitute), and this is my take on this " established vs new " pt.

1) If you or anyone doing similar level of care WHEN you were at that

practice, under a Tax ID that you contributed, saw that pt within the last 3

years, EVEN IF you now start you own practice, you should bill established

pt care level.

2) If a specialist (sort of think you're a primary care doc) in your

multispeciality group at that time was the ONLY one who saw that pt within

the past 3 years, would think you should be able to bill as NEW pt.

3) Truly, it's a relationship thing. If I've known that pt within the past

3 years, the pt feels I was the primary care doc, OR another doc in primary

care WHILE I WAS THERE was their primary doc, I bill established.

Not worth the risk-- it's easier, of course, with a computerized system

holding visits, and I can look them up. Fortunately, I can still with

minimal difficulty get that info from the old office if there's a doubt-- we

usually do this with a records release and if question of appropriate follow

up issues, not for billing.

Dr Levin

Family Medicine

Pittsburgh, PA

billing new/established after move

> That's a good (and important) observation of finances to share for us in

> the process of making the leap -- thanks. Financial plans should remain

> conservative even if the initial months look great. Earnie's point later

> about the initial follow up appts of many patients supports that idea too.

>

> But this reminds me of something I meant to ask previously. For those of

> us setting up shop near our old offices, when patients of the prior office

> switch and are seen in the new site, is the billing for a new patient or

> for an estabished patient?

>

> My current situation is confusing by my belonging to a multi-specialty

> group. Even if a patient is seen in a different center and transfers to

> my care, I must bill as an established patient d/t to rule of being seen

> by a colleague.

>

> But with the upcoming move, there will be the initial administrative work

> and coordinating of records with review, etc, so even if I have been

> seeing a patient in the old office, once they move to my new office I can

> imagine billing as a new patient.

>

> Anyone have a clear understanding of this?

> Tim

>

>> Ernie:

>>

>> Glad everything going smoothly. Great numbers to start. keep us

>> informed as the clinic ages the ratio of new to follow up visits

>> changes and we experienced a dip in AR at about 6 months and one year.

>>

>> Leland wrote:

>> st1\:*{behavior:url(#default#ieooui) } Hi all-

>>

>> When I was doing the pro-forma for our clinic, I found numbers from

>> existing clinics helpful. So here are ours. I keep intending to do

>> an analysis of all our numbers so far, but don't get to it. Here are

>> some of our preliminary results:

>>

>> We opened August 1, 2005. These are for our first five months. We

>> opened in a modified low overhead. We are in a 1,000 square feet with

>> one office available for another physician hopefully this august. We

>> purchased e-MD's complete EMR/PMS. We bought the recommended servers

>> and equipment. (The generic versions though, not Dell.) We have just

>> purchased a CLIA Waived Lipid system and an A1c testing system. (More

>> on those below.) We handed out a lot of three fold brochures to

>> nurses at the hospital and other doctors. (This and being listed on

>> insurance company web sites are our primary form of advertising.) We

>> donate 10% of our proceeds to charity. We do our own billing.

>>

>> Elise is the doctor. I am the part time business guy and receptionist

>> up until we hired . I have been working about one day a week

>> since then. is an MA who acts as a receptionist and nurse.

>> She is working with high cholesterol patients. (Giving a introduction

>> to cholesterol appointment with suggestions, literature, a work out

>> and diet journal. She follows this up with calls to see how they are

>> doing and another lipid panel at two months.) We are hoping to add

>> diabetes and hypertension to the list soon. She is also setting up a

>> mothers group for our single mothers. (We found that a lot of them

>> were suffering with depression and looking for nonjudgmental support.)

>>

>> We added the Lipid and A1c test simply so that we could have the

>> results before the appointment if we new the patient needed them,

>> eliminating the need to call with results. It doesn't take much

>> longer that drawing blood to send to the lab and doesn't involve

>> needles, just a finger stick. (Hey, it's our ideal practice.)

>>

>> Now to the actual results:

>> Total patients: 330 about 80 who followed Elise

>> Total visits: 620

>> Total collected to date: $48,131

>> Total AR less than one month old: $17,440

>> Total AR over one month: $2,000

>> Locum Tenum income: $4,680 (This is in addition to the collected

>> amount.) Operating Expenses: $24,000

>> Our salary: $40,000

>> We were able to pay our expenses in the second month without salary.

>>

>> We borrowed about $79,000 which was spent on:

>> Computers and software (anything electronic): $31,000

>> Testing equipment: $4,000

>> Office furnishings: $9,000

>> Start-up (licensing, etc.): $2,000

>> Expenses and salary: $24,000

>> Cash on hand: $7,000

>> Pre-paid expenses: $2,000

>>

>> Our monthly cash inflow from patient visits was:

>> August $200

>> September: $5,500

>> October: $8,100

>> November: $15,380

>> December: $19,000

>>

>> We were fairly conservative until about month two. Then we spent more

>> on things we wanted as it became assured that we would have the visits

>> to support our clinic long term. We don't anticipate doing another

>> draw on our operating line. We do anticipate starting to pay it down

>> soon. We do not have additional big ticket items to purchase. We

>> could have spent less on our computers, skipped the testing equipment

>> for a while, spent less decorating and on furnishings. I would not

>> trade e-MD's for a different system.

>>

>> Cheers,

>> Ernie Leland

>> Orchards Family Medicine, Inc.

>>

>> ---------------------------------

>> YAHOO! GROUPS LINKS

>>

>> Visit your group " " on the web.

>>

January 7, 2006

I don't have the numbers right in front of me, but I'm almost certain that a

99203 will pay quite a bit higher than a 99214 maybe $20 or more?).

>

> Date: 2006/01/07 Sat AM 10:58:37 EST

> To: < >

> Subject: Re: billing new/established after move

>

> I don't have our fee schedule at home to clarify, but has anyone considered

that USUALLY, you can bill a higher E & M level for an established pt with same

problems than for a new one, because you only need 2 of 3 components, with the

exam often being a limiting factor with new pts. Just asking-what is the

difference in the fee, for instance, for 99214 vs. 99203? I looked into this

before because I was " irate " that I was seeing a lot of patients transferring

from another office in our ambulatory system, and I was told I had to code as an

established pt. because the system all had the same Tax ID # so they were

established with the system. When I checked into the difference, realizing

usually you can use the higher E & M level, it was not that much different, but I

can't recall the details in dollars.

>

> Just a thought.

> RE: billing new/established after move

>

> I think an ethically sound argument to go either way on this issue.

> Maybe the way ahead is to ask a major insurer to weigh in? This way if you

do bill as new for the burden of administrative work and are later challenged,

you could cite their own advice.

> Gordon

> At 08:33 AM 1/7/2006, you wrote:

>

> Lynn and Annie - thanks. What you both say matches things I've casually

> heard in the past. That is, the issue is confusing! I can see the logic

> in both sides of the argument -- that a patient has been seen by me, thus

> is not " new " BUT considering the concept of new patients involving extra

> work administratively and in organizing old records I can imagine billing

> as " new " still I'll still have the extra work as part of the care.

>

> For 8 years it's been a hassle to have an essentially new patient

> transferring internally (with record transferred from another facility in

> our system) and only being able to bill as " established " ... emotionally I

> feel like insurance should cut me a break after getting away from that.

> But, of course, insurers don't have emotions, do they! ;-)

>

> Anyone actually have claims denied or downcoded after they billed as new

> for a patient transferring from a prior office?

> Tim

>

> > I had been told the same thing, but when I started my own practice, the

> > consultant and the billing company both insisted that EVERY patient was

> > a new patient the first time they came to my NEW practice and got billed

> > under my new billing numbers. That was in 7/02 and all claims were

> > paid as new patients with no fuss from insurers.

> > Annie

> >

> > -----Original Message-----

> >

January 7, 2006

I discussed this with my medical consultant (who used to work for a large

insurance group locally) and my prior group billing people, and they both

gave me the same answer:

If the patient had been seen by me in my prior group setting in the last 3

years, then they are an established patient when I see them in my new

practice.

If the patient had been seen in my former group, but not by me in the last 3

years, then they are considered a new patient. (While I was in the group,

if the patient had been seen by someone in the same group, even in a

different office, that was in my specialty (FP), in the last 3 years, then

they were an established patient the first time I saw them).

So, if you have seen them in the last 3 years, regardless of what office/tax

ID#, then they are an established patient. If you have never seen them in

the last 3 years, then they are new. I guess the insurance companies expect

us to be able to remember all those details about our patients for 3

years...

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

RE: billing new/established after move

I had been told the same thing, but when I started my own practice, the

consultant and the billing company both insisted that EVERY patient was

a new patient the first time they came to my NEW practice and got billed

under my new billing numbers. That was in 7/02 and all claims were

paid as new patients with no fuss from insurers.

Annie

-----Original Message-----

January 7, 2006

I agree with Annie. My understanding was that the reason that new patient codes pay more than the same level of established patient codes is to compensate the extra work involved in setting up a new patient account - registering the patient, starting a new chart for them, etc. So if a physician changes practices and the patient follows them to the new practice, the new practice should bill the first visit as a new patient since they have to do all the work involved in setting up a new patient. I recently changed practices, and am following this rule. R. , M.D., M.P.H.Annie Skaggs wrote: I had been told the same thing, but when I started my own practice, theconsultant and the billing company both insisted that EVERY patient wasa new

patient the first time they came to my NEW practice and got billedunder my new billing numbers. That was in 7/02 and all claims werepaid as new patients with no fuss from insurers. Annie-----Original Message-----From: To: Subject: RE: billing new/established after moveThere's an article in FPM about coding new vs established and if you'veseen them in any capacity, even completely different facility, not your oldone, in the past 3 years, they are established. I can try to dig up the linkfor you if need me to.Lynn>But this reminds me of something I meant to

ask previously. For thoseof>us setting up shop near our old offices, when patients of the prioroffice>switch and are seen in the new site, is the billing for a new patientor>for an estabished patient?>>

January 7, 2006

Medicare tracks you by your UPIN and will not pay new visits on patients you have previously seen in the last three years. I know this from experience with non-payment of initial visits. However the coding books suggest that this is a new clinic and thus each patient may be considered a new patient. I think this boils down to insurance company's ability to track you and your unique patient encounters. If the visists were billed under a different provider number and group number, they cannot track you. My wife and I have no record of who or when we saw patients at the last practice, so we bill new patient visits unless we clearly remember the patient. Eads wrote: I discussed this with my medical consultant (who used to work for a largeinsurance group locally) and my prior group billing people, and they bothgave me the same answer:If the patient had been seen by me in my prior group setting in the last 3years, then they are an established patient when I see them in my newpractice.If the patient had been seen in my former group, but not by me in the last 3years, then they are considered a new patient. (While I was in the group,if the patient had been seen by someone in the same group, even in adifferent office, that was in my specialty (FP), in the last 3 years, thenthey were an established patient the first time I saw them).So, if you have seen them in the last 3 years, regardless of what office/taxID#, then they are an established patient. If you have never seen them inthe last 3 years, then they are new. I guess the insurance companies expectus to be

able to remember all those details about our patients for 3years... A. Eads, M.D.Pinnacle Family Medicine, PLLC phone faxP.O. Box 7275Woodland Park, CO 80863-----Original Message-----From: [mailto: ] On Behalf Of Annie SkaggsSent: Saturday, January 07, 2006 6:13 AMTo: Subject: RE: billing new/established after moveI had been told the same thing, but when I started my own practice, theconsultant and the billing company both insisted that EVERY patient wasa new patient the first time they came to my NEW practice and got billedunder my new billing numbers. That was in 7/02 and all claims werepaid as new patients with no fuss from insurers. Annie-----Original Message-----Yahoo! Groups

Links

Yahoo! DSL Something to write home about. Just $16.99/mo. or less

January 8, 2006

This does seem to be a very confusing issue, and it appears the list-serve is

evenly divided as to what is the right " thing to do. "

I decided to go ahead an bill everyone as a new patient, as I feel one of the

more time-consuming parts of a new practice is restarting a patient data base.

I do not feel the extra reimbursement for the new patient charge is to pay us

for the establishment of a new relationship, but that it was intended to

reimburse for the time and energy in creating a chart, patient demographics

info, etc.

I have been open since June 2005 and have not had any trouble with new patient

reimbursement issues, including Medicare. I still have the same UPIN that I

have had for the past 10 years, but I am billing under a completely new tax

ID.

Hope this helps.

, MD

Durango, CO

On Sat, 7 Jan 2006 13:47:49 -0800 (PST)

Egly wrote:

> Medicare tracks you by your UPIN and will not pay new visits on patients you

>have previously seen in the last three years. I know this from experience

>with non-payment of initial visits.

>

> However the coding books suggest that this is a new clinic and thus each

>patient may be considered a new patient.

>

> I think this boils down to insurance company's ability to track you and

>your unique patient encounters. If the visists were billed under a different

>provider number and group number, they cannot track you.

>

> My wife and I have no record of who or when we saw patients at the last

>practice, so we bill new patient visits unless we clearly remember the

>patient.

>

> Eads wrote:

> I discussed this with my medical consultant (who used to work for a large

> insurance group locally) and my prior group billing people, and they both

> gave me the same answer:

>

> If the patient had been seen by me in my prior group setting in the last 3

> years, then they are an established patient when I see them in my new

> practice.

>

> If the patient had been seen in my former group, but not by me in the last 3

> years, then they are considered a new patient. (While I was in the group,

> if the patient had been seen by someone in the same group, even in a

> different office, that was in my specialty (FP), in the last 3 years, then

> they were an established patient the first time I saw them).

>

> So, if you have seen them in the last 3 years, regardless of what office/tax

> ID#, then they are an established patient. If you have never seen them in

> the last 3 years, then they are new. I guess the insurance companies expect

> us to be able to remember all those details about our patients for 3

> years...

>

> A. Eads, M.D.

> Pinnacle Family Medicine, PLLC

> phone fax

> P.O. Box 7275

> Woodland Park, CO 80863

> RE: billing new/established after move

>

> I had been told the same thing, but when I started my own practice, the

> consultant and the billing company both insisted that EVERY patient was

> a new patient the first time they came to my NEW practice and got billed

> under my new billing numbers. That was in 7/02 and all claims were

> paid as new patients with no fuss from insurers.

> Annie

>

> -----Original Message-----

>

January 9, 2006

We were told the same thing, from a medical practice consultant, as states below. When we opened in July 03, If Rian had seen a patient in the last 3 years, that person was considered an established patient, even though Rian had a new office and a new tax id.

a Mintek

Allegan, MI

RE: billing new/established after move

I discussed this with my medical consultant (who used to work for a largeinsurance group locally) and my prior group billing people, and they bothgave me the same answer:If the patient had been seen by me in my prior group setting in the last 3years, then they are an established patient when I see them in my newpractice.If the patient had been seen in my former group, but not by me in the last 3years, then they are considered a new patient. (While I was in the group,if the patient had been seen by someone in the same group, even in adifferent office, that was in my specialty (FP), in the last 3 years, thenthey were an established patient the first time I saw them).So, if you have seen them in the last 3 years, regardless of what office/taxID#, then they are an established patient. If you have never seen them inthe last 3 years, then they are new. I guess the insurance companies expectus to be able to remember all those details about our patients for 3years... A. Eads, M.D.Pinnacle Family Medicine, PLLC phone faxP.O. Box 7275Woodland Park, CO 80863-----Original Message-----From: [mailto: ] On Behalf Of Annie SkaggsSent: Saturday, January 07, 2006 6:13 AMTo: Subject: RE: billing new/established after moveI had been told the same thing, but when I started my own practice, theconsultant and the billing company both insisted that EVERY patient wasa new patient the first time they came to my NEW practice and got billedunder my new billing numbers. That was in 7/02 and all claims werepaid as new patients with no fuss from insurers. Annie-----Original Message-----

January 9, 2006

The spirit of the 'new' vs 'established' determination is not up to us,

unfortunately.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

RE: billing new/established after move

>

> I had been told the same thing, but when I started my own practice, the

> consultant and the billing company both insisted that EVERY patient was

> a new patient the first time they came to my NEW practice and got billed

> under my new billing numbers. That was in 7/02 and all claims were

> paid as new patients with no fuss from insurers.

> Annie

>

> -----Original Message-----

>

January 9, 2006

If any one is interested, here's the link to the FPM coding article about

established vs new:

http://www.aafp.org/fpm/20030900/33unde.html

Lynn Ho

January 9, 2006

No, alas, the " spirit " may not be up to us, but making a living is.

, M.D.

Durango, CO

On Sun, 8 Jan 2006 18:54:15 -0700

" Eads " wrote:

> The spirit of the 'new' vs 'established' determination is not up to us,

> unfortunately.

>

> A. Eads, M.D.

> Pinnacle Family Medicine, PLLC

> phone fax

> P.O. Box 7275

> Woodland Park, CO 80863

>

> RE: billing new/established after move

> >

> > I had been told the same thing, but when I started my own practice, the

> > consultant and the billing company both insisted that EVERY patient was

> > a new patient the first time they came to my NEW practice and got billed

> > under my new billing numbers. That was in 7/02 and all claims were

> > paid as new patients with no fuss from insurers.

> > Annie

> >

> > -----Original Message-----

> >

January 9, 2006

Thanks, very good article.

RE: billing new/established after move

If any one is interested, here's the link to the FPM coding article about established vs new:http://www.aafp.org/fpm/20030900/33unde.htmlLynn Ho

January 9, 2006

I have to agree. It is a well defined area, even if it is not what we

want to hear. I think it would be great if we could just code

everything as a 99204 for maximum reimbursement, but that would be

fraud. I would be careful in doing things by spirit rather than clearly

defined (if a bit obscure) guidelines. The Evaluation and Management

Services Guidelines from the AMA in CPT 2005 states the guidelines just

like the article in the link. I would suggest hiring new consultants if

they do not understand the rules surrounding opening a new clinic.

Spreading the wrong information, even if some people get away with it,

leads to headlines like " Doctors steal MILLIONS from Medicare. "

Another way to think about it: I can get away with not paying taxes and

pocketing my co pays, probably. Unless I end up in jail for tax

evasion. I can get away with over coding and pocketing the extra,

probably. Unless I end up in jail for Medicare (or Insurance) fraud. A

lot of things in life are gray areas, just be glad that this is one

where there is a clear right and wrong.

Stand proud with your expertise, your compassion, and your new clinic.

You will make plenty of money in the long run.

Ernie

RE: billing new/established after move

The spirit of the 'new' vs 'established' determination is not up to us,

unfortunately.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

Sign In

RE: billing new/established after move

Recommended Posts

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Guest guest

Join the conversation

Activity