Ever Want To Know What EM Codes are Considered "New Patient" Codes?

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. TheRecovery A
uditors have identified claims with "New Patient" Evaluation and Management (E&M) services to have improper payments, because the new patient services have been billed two or more times within a 3-year period by the same physician or physician group.

The"Medicare Claims Processing Manual," Chapter 12, Section30.6.7 provides that “Medicare interpretthe phrase “new patient” to mean a patient who has not received any professional services, i.e., E&M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.”

As a result of over payments for new patient E&M services that should have been paid as established patient E&M services, CMS will implement changes to the CWF to prompt CMS contractors to validate that there are not two new patient CPTs being paid within a three year period of time.

The new patient CPT codes that will be checked in these edits include 99201-99205, 99324-99328,99341-99345, 99381-99387,92002, and 92004.

The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012, and 92014).

If Medicare discovers that a new patient code has been paid more than one time in a 3-year period to the same physician, then Medicare contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.