In eye care, we see many mergers, acquisitions and changes of ownership. An important question follows in their wake: What is the status of the patients in these practices? Once the deal closes, are these patients considered new or established?

The question is simple, but the answer is not.

The Centers for Medicare & Medicaid Services and the Recovery Auditors (RA) both consider this topic of status important enough for continuous monitoring.¹

Q. What is the definition of a new patient?

A. CPT publishes the following definition:²

“A new patient is one who has not received any professional services from the physician/qualified health-care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.”

The phrase “and subspecialty” was added in 2012 but is not helpful because the physician specialties within the CMS Provider Enrollment, Chain and Ownership System (PECOS) cannot distinguish between subspecialties within ophthalmology, such as retina, glaucoma or cornea.³ Even with new taxonomy codes assigned to some subspecialties, the Medicare Claims Processing Manual (MCPM) Chapter 26 §10.8.2 only segregates ophthalmology (18) and optometry (41), as explained in CMS’ guidance on this topic.⁴

“Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. … Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare … the same specialty is determined by the physician’s or practitioner’s primary specialty enrollment in Medicare. …”

So, as a practical matter when considering whether a patient is “new,” all ophthalmologists are the same. For example, when Dr. Cataract sees an established patient and refers the patient to her partner, Dr. Retina, who sees the patient one month later for the first time, the patient is established for Dr. Retina since both ophthalmologists are in the same specialty and in the same group practice.

Other payers’ reimbursement policies generally follow the same guidelines as those of CPT and CMS.

Q. What are some examples?

A. Let’s consider several potentially confusing scenarios.

1. A physician leaves his old practice to join a new practice. Several of his established patients follow him to the new practice. These patients are established when seen by the physician in the new practice, because the physician’s NPI demonstrates previous professional encounter(s).
2. An ophthalmologist joins a new practice. His former patient calls for an appointment, but because his schedule is full, the front desk schedules the patient with a different ophthalmologist in the new group. This patient is a new patient seen under a new practice tax ID and there is no prior NPI relationship.
3. Dr. Oculoplastic contracts with five different practices. Sometimes he sees his patients in more than one practice. When he sees those patients at different practices with different tax IDs, they are established because Dr. Oculoplastic’s NPI shows a professional relationship with the patient.
4. Dr. Junior is a young ophthalmologist who joins a practice in anticipation of Dr. Senior’s retirement. Dr. Senior starts transferring patients to Dr. Junior. These patients are established for Dr. Junior since Dr. Senior and Dr. Junior are of the same specialty in the same practice.

Q. We have a nurse practitioner (NP) in the group. Would her first visit with an otherwise established patient be considered “new”?

A. Sometimes; when the NP is acting on her own, such as doing history and physicals, she is considered a different specialty. However, when NPs or physician assistants work “incident(ly) to” a physician, they are considered to be working in the same specialty as the physician;² so do not bill a new patient exam in this situation. OM

REFERENCES

1. Performant Recovery. Issues Under Review. Issue A000072009. Posted March 9, 2017. http://www.performantrac.com/IssuesUnderReview.aspx . Accessed April 19, 2017.
2. 2017 CPT Current Procedural Terminology. American Medical Association.
3. Medicare Claims Processing Manual. Chapter 26, Completing and Processing Form CMS-1500 Data Set. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf . Accessed April 19, 2017.
4. CMS, Frequently Asked Questions; New Patient. https://questions.cms.gov/faq.php?id=5005&faqId=1969 . Accessed April 19, 2017.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .