Medical Billing Service Advice – How to Determine Patient Status

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By Michelle Stahl, Owner, Physicians Billing Service

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Determining patient status can be fairly complex for medical billers.  Recently, I read an insightful article published by SuperCoder Bolt that provides succinct medical billing service advice.

The article, entitled, ‘Back to Basics:  Follow The 3-Year Rule to Determine Patient Status’, by R. Pandit,  offers the following insights:

  1. New or Existing Patient:  selecting the right evaluation and management (E/M) code depends on the definition for new or established patients.  As the article notes, follow the 3 (three) year rule, and there is a very specific definition for an “established” patient.  Specifically, the article notes that “an established patient is one who has received professional services form the physician  / qualified healthcare professional for another physician / qualified healthcare professional of the exact same specialty and sub-specialty who belongs to the same group practice, within the past three years”.  The guidelines are fairly clear, in that if the patient remains within a group practice for the same professional services, and has been seen within a 3 year period, the patient is classified as “established”.
  2. Do Not Use Location to Determine the Patient Status for “new” or “established”.  As the article notes, “based on CPT (Current Procedural Terminology) established patient definition, new versus established refers to the patient’s relationship to the physician, not his relationship to the practice or its location”.

What if the Physician Changes Practices?

As a medical billing service that has been assisting leading medical practices, since 1989, we have had experiences where Physicians have switched practices.  As you are probably aware, if the Physician has seen the patient in the last 3 years, that patient should still be classified as an “existing” patient.  Medical Payers “will look at the provider’s National Provider Identifier (NPI), not where the service was provided”, notes the article.

To read the full article, visit the SuperCoder Bolt publication online.

Physicians Billing service is a leading outsourced medical billing service.  We provide award winning service from coast to coast including:  Boston MAPeabody MAPanama City FL and Baltimore MD.

Four a medical billing service quote, call Michelle Stahl, Owner, at 240-382-2455 or use the Physicians Billing Service online contact form.


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We are proud to support leading Physicians & Medical Practices through-out Florida, Maryland, Washington DC, Virginia, Pennsylvania, New Jersey & New York. Your commitment to excellence inspires us! Since 1989, Physicians Billing Service has been committed to excellence in Medical Billing & Collections.

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