New Patient Evaluation and Management Codes: Correct Claim Submission

Published 08/03/2020

The Centers for Medicare & Medicaid Services (CMS) has identified a problem in the way claims are being submitted for new patient office or other outpatient visit codes (CPT codes 99201–99205).

The definition of a new patient, for Medicare purposes, comes from the CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 30.6.7A and states:

"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 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. 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."

As many providers are aware, the recovery audit contractor (RAC) has been collecting such overpayments that have occurred falling within the above scenario.  

Please be cautious when submitting new patient CPT codes 99201 through 99205. If there has been a prior face-to-face visit by you or the same specialty within your group within the previous three-year period, do not submit a new patient code. Submit the applicable established visit code instead.  

Palmetto GBA will monitor claims submitted with multiple "new patient" face-to-face services within three-year periods. Two physicians that are both members of the same group and that have the same designated primary specialty submit a "new patient" claim, Palmetto GBA will deny the second "new patient" service with reason code B16 (New patient qualifications were not met). Palmetto GBA will determine whether the specialties are the same based on the primary specialty you designated during the enrollment process.

Reference: CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15 (PDF, 1.42 MB), Section 60.

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