Practice Management

Can  you please clarify new patient vs established patient.
1. Patient had an US done by MFM, no E/M service provided at this time.  Patient is sent back to MFM during same pregnancy for US and E/M, is this E/M new or established?
2. Patient was seen for pregnancy A with or W/O an E/M, is then seen for pregnancy B by MFM 2.5 years later with new pregnancy for an E/M, would this be a new or established?

Thank you for your time.

Penni Savignac, CPC

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Penni Savignac
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Original Message:
Sent: 7/25/2022 8:50:00 AM
From: Penni Savignac
Subject: New Patient VS Established Patient

Can  you please clarify new patient vs established patient.
1. Patient had an US done by MFM, no E/M service provided at this time.  Patient is sent back to MFM during same pregnancy for US and E/M, is this E/M new or established?
2. Patient was seen for pregnancy A with or W/O an E/M, is then seen for pregnancy B by MFM 2.5 years later with new pregnancy for an E/M, would this be a new or established?

Thank you for your time.

Penni Savignac, CPC

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Penni Savignac
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Hello Penni,

The 3-year criteria used by many payers to determine "NEW" vs. "ESTABLISHED" refers to E/M, not procedures. Interpreting an ultrasound only does not count or reset the clock towards new/established determination. In the first example you gave, the E/M visit would be a NEW encounter. In the second example, it would be an established visit if an E/M was also done 2.5 years earlier, or a new visit if no E/M visit was done 2.5 years earlier.
Please note that MFM providers in the same practice will count as one and the same for the 3-year rule. This means if MFM-A saw the patient 2.5 years ago for an E/M visit and MFM-B from the same practice saw the patient in her second pregnancy for an E/M visit, MFM-B will count that encounter as an established visit even if MFM-B had never seen the patient in the past.
Certain payers may also have different rules than the 3-year standard rule for new/established, which would be stated in your contract with that payer.

Best Regards,
Fadi

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Fadi BSAT, MD, FAIUM
Past Chair, SMFM Coding Committee
Chair, SMFM Practice Management Division
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Original Message:
Sent: 07-25-2022 08:49
From: Penni Savignac
Subject: New Patient VS Established Patient

Can  you please clarify new patient vs established patient.
1. Patient had an US done by MFM, no E/M service provided at this time.  Patient is sent back to MFM during same pregnancy for US and E/M, is this E/M new or established?
2. Patient was seen for pregnancy A with or W/O an E/M, is then seen for pregnancy B by MFM 2.5 years later with new pregnancy for an E/M, would this be a new or established?

Thank you for your time.

Penni Savignac, CPC

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Penni Savignac
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Thank you so much for the clarification.

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Penni Savignac
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Original Message:
Sent: 07-26-2022 10:00
From: Fadi BSAT
Subject: New Patient VS Established Patient

Hello Penni,

The 3-year criteria used by many payers to determine "NEW" vs. "ESTABLISHED" refers to E/M, not procedures. Interpreting an ultrasound only does not count or reset the clock towards new/established determination. In the first example you gave, the E/M visit would be a NEW encounter. In the second example, it would be an established visit if an E/M was also done 2.5 years earlier, or a new visit if no E/M visit was done 2.5 years earlier.
Please note that MFM providers in the same practice will count as one and the same for the 3-year rule. This means if MFM-A saw the patient 2.5 years ago for an E/M visit and MFM-B from the same practice saw the patient in her second pregnancy for an E/M visit, MFM-B will count that encounter as an established visit even if MFM-B had never seen the patient in the past.
Certain payers may also have different rules than the 3-year standard rule for new/established, which would be stated in your contract with that payer.

Best Regards,
Fadi

------------------------------
Fadi BSAT, MD, FAIUM
Past Chair, SMFM Coding Committee
Chair, SMFM Practice Management Division

Original Message:
Sent: 07-25-2022 08:49
From: Penni Savignac
Subject: New Patient VS Established Patient

Can  you please clarify new patient vs established patient.
1. Patient had an US done by MFM, no E/M service provided at this time.  Patient is sent back to MFM during same pregnancy for US and E/M, is this E/M new or established?
2. Patient was seen for pregnancy A with or W/O an E/M, is then seen for pregnancy B by MFM 2.5 years later with new pregnancy for an E/M, would this be a new or established?

Thank you for your time.

Penni Savignac, CPC

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Penni Savignac
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