New versus Established and Change of Tax ID#

If your posts are directly related to compliance issues related to OIG, Stark, creating a Compliance Plan, compliance policies, or any other type of compliance need- post here. Also, check out the threads and add your comments to the threads here.

Moderators: NAMAS Moderator, Shannon DeConda

Post Reply
Posts: 2
Joined: Thu Feb 22, 2018 7:03 pm

Thu Feb 22, 2018 7:33 pm

:D Hello,

We have an internal debate going on the rules for New versus Established patient specifically for patients following a provider from one local clinic to another local clinic within the 3yr period (same rendering provider NPI with different Group Tax ID numbers).

In this situation; would the patient be considered "New"; since they have never been seen at the new Group location ? Or are they Established because they have already seen the provider within the 3yr period ?

Please site the guidelines supporting your response.

Charlene DiGiacomo, COC
Posts: 11
Joined: Fri Apr 13, 2018 11:54 am

Fri Apr 13, 2018 12:21 pm

Hi Charlene,

It will be considered established patient, if the patient comes within the 3 years time frame. Here is a Q/A from Noridian. See "Claim Examples 2."
A patient sees Dr. Smith, a cardiologist, for follow up care at "Clinic A."

Date of Service Service Provided CPT Code
06/23/17 Established E/M 99213
Dr. Smith leaves "Clinic A" and joins "Clinic B." The patient follows Dr. Smith to "Clinic B."

Date of Service Service Provided CPT Code
7/15/17 Established E/M 99213
Although Dr. Smith is at a different clinic, the patient is still an established patient with him. Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years.
I have attached the full article from Noridian's Website. I have also attached their E/M Webinar that states this on slide 14.

New Patient vs Established Patient Visit - Noridian.pdf
(143.38 KiB) Downloaded 1196 times
New Patient Versus Established Patient Visits Presentation.pdf
(595.84 KiB) Downloaded 1139 times
Corporate Compliance Analyst
Seattle Children's Hospital
Seattle, WA
Posts: 2
Joined: Thu Feb 22, 2018 7:03 pm

Fri Apr 13, 2018 1:16 pm

Thanks Bill..... great information !
Post Reply