California Chapter Recognized at
Annual Board of Governor Meeting in Las Vegas
Incoming Board of Governor Chair, Dipti Itchhaporia, MD, FACC, recognized the California Chapter for excellence in the area of Membership and Community.

Problems Billing "new patient" Services
The Centers for Medicare & Medicaid Services (CMS) has determined a large vulnerability is occurring by providers submitting services for CPT New Patient Office or Other Outpatient Visit Codes 99201 through 99205.  The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.7a reads as follows:

CMS has defined 'new patient' as:
Definition of New Patient for Selection of Evaluation and Management (E/M) Visit Code
Interpret the phrase 'new patient' to mean a patient who has not received any professional services (e.g., 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 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 most providers are aware, the Recovery Audit Contractor (RAC) has been collecting such overpayments that have occurred falling within the above scenario.
Providers are encouraged to be very cautious when billing the CPT New Patient 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 bill a new patient code. You should bill the applicable established visit.

Palmetto GBA will monitor to identify multiple 'new patient' face-to-face services within three-year periods. If you and a member of your group with 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 monitor to ensure that 'new patient services - CPT Codes 99201 through 99205' are billed by physicians only (CMS IOM Manual Publication 100-02, Chapter 15, Section 60).

Note: Medicare will select 'same' specialty based on the primary specialty you designated during the enrollment process.

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