New Patient Visits by the Same Physician or Physician Group
Medicare's Common Working File (CWF) system detects erroneous billings when there are two new patient CPT codes being billed within a three-year period of time by the same physician or physician group.
If Medicare discovers that a new patient code has been paid more than one time in a three-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.
Codes that Are Checked
- CPT codes: 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)
New Patient Definition:
The Medicare Claims Processing Manual Chapter 12, Section 30.6.7, provides that Medicare interprets 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 three years. For example, if a professional component of a previous procedure is billed in a three-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).
Resource: MLN Matters 8165 (PDF, 90 KB).