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Resolved New vs Established

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LynaeM_46254

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Has anyone had issues with RHC vs free standing or PBC with Commercial insurances regarding new vs established patients?
 
I have not seen any posts on social media over commercial insurance regarding this topic myself.

Medicare definition

“Interpret the 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. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”
CPT® definition

“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s). A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

CCO - New vs Established.png


HCPCS/Accommodation Rates/HIPPS Rate Codes, FL 44
For all services provided in a FQHC on or after January 1, 2010 and for approved
preventive services provided in a RHC, HCPCS codes are required to be reported on the
service lines.
The following HCPCS codes must be reported on FQHC PPS claims:
HCPCS Code Definition
G0466 FQHC visit, new patient
A medically-necessary, face-to-face encounter (one-on-one) between a new
patient and a FQHC practitioner during which time one or more FQHC services
are rendered and includes a typical bundle of Medicare-covered services that
would be furnished per diem to a patient receiving a FQHC visit.
G0467 FQHC visit, established patient
A medically-necessary, face-to-face encounter (one-on-one) between an
established patient and a FQHC practitioner during which time one or more
FQHC services are rendered and includes a typical bundle of Medicare-covered
services that would be furnished per diem to a patient receiving a FQHC visit.
G0468 FQHC visit, IPPE or AWV

 
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