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Fighting Fraud

New Patient or Established Patient

If your confused, you might be on the OIG's radar this year

The OIG has had Evaluation and Management services on their annual "Hit List," or Work Plan, as it is generally referred to for the past several years. In 2012, CMS finally got its wish - Evaluation and Management codes, finally were included in RAC Audits, as announced on September 18, 2012. So it's no surprise to see these codes under scrutiny for 2014. What is different this year, is the focus on Medicare payments for E&M New Patient visits made to hospital clinics. The OIG and CMS, seem to feel that there have been some overpayments made in this area and think that many New Patient visits, should have been billed by hospital clinics as Established Patient visits instead.

The OIG is going to be conducting reviews for 2014, of said Medicare visits that were rendered in a hospital outpatient clinic and billed as New Patient visits, utilizing E&M codes 99201 - 99205. The OIG has already done some initial data mining, which assisted them in determining that Medicare has indeed made overpayments in this area and they are looking to determine exactly how large a scale the overpayment issue is.

Clinic Concerns

Hospital outpatient clinics are tasked with identifying patients who present for outpatient clinic services, as either "New" or "Established". The hospital clinics determine this by tracking past encounters from patients in different departments within the hospital. The rule of thumb, according to Federal regulations is "if a patient has been seen as a registered inpatient or outpatient within the past 3 years, then the patient is considered to be "Established." (73 Fed. Reg. 68679 (November 18, 2008).) (OAS; W-00-12-35627; W-00-14-35627; expected issue date: FY 2014; work in progress).

The 2012 RAC Audits indicated some over-utilization on higher-level E/M codes, in several specialties that included: Family Practice, Internal Medicine and Emergency medicine. Of note, is that these 3 specialties represented 80 percent of the 66 specialties reviewed per the 2012 report.

  • 19.8 percent internists
  • 12.2 percent family physicians
  • 9.9 percent emergency medicine.
The initial OIG report in May, 2012, tasked CMS to audit E&M codes, as they typically have a higher propensity for fraud and abuse. The OIG report indicated that from 2001 through 2010, CMS's payouts for Part B services skyrocketed to 43 percent - going from close to $77 billion to a staggering $110 billion. Of that $110 billion, $33 billion was in E&M payouts alone! That's a red flag if ever I saw one.

If you noticed, two of the three specialties of focus, are often seen within hospital clinic walls and as if to really scare the bejesus out of you, the OIG was able to pinpoint close to 1700 outliers on the 2012 report, so the OIG will be able to "knock" on their doors as necessary. Is it any wonder now that the OIG's Work Plan has continued to include E&M visits again for 2014? To review the report, please click on the link: https://oig.hhs.gov/oei/reports/oei-04-10-00180.asp

Location, Location, Location

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Is usually the issue and is one of the reasons for confusion in the hospital clinic setting. In a hospital setting there are numerous departments and for providers, it can be a somewhat confusing point of frustration when it comes to determining if a patient is either "New" or "Established."
A patient can present in the Emergency Department and be treated and can be seen by the ER provider and a number of other providers during the same visit. The confusion lies with other specialty providers who treat the patient during the same encounter in the Emergency Department and the aftercare provided at a hospital clinic for the first time.

If a patient presents to a Cardiologist within a hospital clinic group and they were seen by another of the same groups Cardiologists in the Emergency Department, that patient is considered to be an Established Patient. If however, a Cardiologist simply read and EKG and provided and interpretation and report, but had not "face to face time" during the patient's course of treatment in the Emergency Department, then when that patient presents to the Cardiology clinic, that patient would still be considered a New Patient, as long as no one within that practice had provided a "face to face" encounter within 3 years.

Audit Prevention - TIPS to help determine New or Established Status

Any time a New Patient visit code is selected, the proper code should come from E&M codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, Typically are spent face-to-face with the patient and/or family).

When it is determined that the patient is Established, the proper code selection should come from one of the following E&M codes 99212 -99215 (Office or other outpatient visit for the evaluation and management of an established patient, Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, Typically, are spent face-to-face with the patient and/or family).


Check Yourself Before You Wreck Yourself - Ramp up on the updated Definitions for New and Established Patients

For new patient office visits, you'll use the following criteria for selecting the appropriate code:
Has the patient received any professional service from the physician or another physician in group of same specialty within last three years? Yes - Established Patient/ No - New Patient

Last year, 2013, added much needed revisions to the E&M definitions for both New and Established patients. The AMA and CPT, as well as other governing bodies, added new wording to the New and Established Patient section in the E/M services guidelines in the front of the CPT® book.

The paragraph below reflects the updated verbiage:
"The definition of a new patient is one who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years".

Similarly, "an established patient is one who has received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years".

Final Thoughts

Evaluation and Management Audits are going to be a permanent fixture for the next several years, as a focal point for potential Fraud and Abuse for the OIG. As healthcare providers, it is imperative that if you work in a hospital clinic setting, that you familiarize yourself with the rules that govern how and when New Patient visit codes and Established Patient visit codes should be coded and billed. The OIG and RAC audits are not going away anytime soon, so be prepared, ensure correct coding and billing by understanding documentation guidelines, conduct internal mock audits and above all "Bullet Proof Your Documentation."

Tools:

"Is Your Environment Compliant?"

Holly Cassano, CPC is director of coding and education compliance, Tactical Management, Inc. (TMI), Winter Park, FL.

Fighting Fraud Archives
 

Scenario: Pt has been seen in the hospital as an IP for pneumonia. 2 yrs later goes to the hospital owned cancer center for breast cancer. Is this patient an established or new pt to the cancer center. The hospital and the cancer center bill under the same NPI. Pt was not seen by any of the same physicians or specialities while in the hospital.

Karen HerboldDecember 23, 2015




     

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