New Patient E/M Edit

If you have received an overpayment request due to MLN Matters MM8165, New Patient E/M edit, then a new patient code has been paid more than one time in a three-year period to the same physician or if one of these new patient CPT codes is paid subsequent to payment of a claim with an established patient CPT code, 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.

  • Has a provider in your group (same group NPI, same provider specialty) billed for and been paid a new patient visit code in the past three years?
    • If so, the payment for which you are being asked to refund monies is for a new patient E/M visit code which does not fall under the definition of a payable new patient visit code and was previously paid.
  • Has a provider in your group (same group NPI, same provider specialty) billed and been paid for an established patient E/M code in the past three years?
    • If so, the payment you are being asked to refund represents and incorrect payment made by Palmetto GBA for a new patient E/M visit code when the service did not meet the definition of a new patient visit.

Providers should not contact the provider contact center to verify when the previous payments were made that have resulted in the determination of an overpayment. Providers should search their individual patient billing history for those services. If you are unable to locate the initial new patient visit or subsequent visit code identified by the edit, you may request an appeal and provide supporting documentation as to why you believe the overpayment request is incorrect.

Providers are encouraged to carefully research their previously paid services for each individual patient prior to submitting an appeal as the patient's billing history maintained by Medicare indicates the new patient visit code you billed and are being asked to refund does not meet the definition of a new patient visit. If it is determined an appeal is appropriate, be sure to include the overpayment AR number (located on the overpayment letter) and submit the appeal to the overpayment appeal address located on the overpayment demand letter.

Interpret the phrase 'New patient' to mean a patient who has not received any professional services, such as an 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. (Physician group practice refers to providers of the same physician specialty billing under the same group NPI.)

To view the MLN Matters article 8165 (PDF, 90 KB). 

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