Clarification - New or Est Problem to provider?

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Clarification - New or Est Problem to provider?

Postby JJones » Wed Aug 16, 2017 10:28 pm


One of our coders has come across an interesting scenario today, and we are not sure how to proceed to bill correctly.

A patient came to one of our Family med providers in February of 2015. He knew he has a dx of hepatitis C, and was looking for a referral to a gastroenterologist, which our provider gave. Our provider did not treat this patient for this condition. The patient went to the referred physician and found that he had to satisfy 6 random drug screenings in order for his insurance to pay for the med that the gastroenterologist prescribed. The patient called our provider's office and explained the situation, our provider said he would be happy to order these random UAs for the patient. The patient never came in nor did he come back to our provider for any other care. Yesterday the patient was seen again by our provider for the same scenario after more than a 2 year span. He is again asking for a referral to the gastroenterologist.

Our question is - would this be an established problem to our provider, or could it be considered new? It has been over 2 years since our provider saw this patient although it was for the same condition.

CLARIFICATION: The patient was new 2 years ago. He is established now, but our question is with the Chief Complaint. It is the exact reason he came in 2 years ago but nothing was ever done then. Now two years later he is ready to be treated. Our provider documented all of this history in the new note. So, would the problem be new because he was never treated, or will it be an established problem to this provider?

Thank you for any advice/direction you can give us. We want to be sure we do this correctly.

Last edited by JJones on Fri Aug 25, 2017 12:30 am, edited 2 times in total.
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Re: New or established problem if not treated in 2 years

Postby admin » Thu Aug 24, 2017 4:00 pm


A new patient is defined as one that has not been seen by the physician, or any providers in the same group/specialty (Tax ID), for three years. Since the provider saw him two years prior, this is an established patient.

I hope this helps!

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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