Medicare E/M claims
for new patients
As previously announced with MM8165, Medicare implemented a common working file
system edit to identify claims where more than one new patient visit was
billed for the same patient within three years. Medicare guidelines only
allow one new patient visit by the same provider or different providers in the
same group with the same specialty, within a three year period.
In addition to this new edit, the common working file has established an
additional edit which identifies claims where an established patient visit was
billed in advance of a new patient visit within a three year period. This
edit fails when the rendering provider on the claim with the established patient
visit is the same as the rendering provider on the claim with the initial
patient visit. As a result of these new edits, you may begin to see
services deny on the original claim submission or you may receive an
overpayment request.
If you receive this denial on a new patient visit (not an overpayment request)
and you determine that the procedure code should have been filed as an
established visit, you can simply call the interactive voice response (IVR)
system and request a reopening. Additional IVR reopening information can be
found by clicking here. If you do not want to use the IVR for this, you have
the option of submitting a new claim or writing in for a reopening.
Note: Submitting a new claim for the revised established E/M visit will
not result in a duplicate denial since the original visit code was not paid.CMS
has mandated that contractors request overpayments on any claims that were
previously paid when either:
An established patient visit was billed prior to an iitial visit within a three
year period by the same rendering provider; or
These new system edits were turned on October 1. A large number of paid claims
have been identified as overpayments due to the above guidelines. As a result,
First Coast Service Options Inc. (First Coast) has initiated recoupment of
improper payments related to these claims. The impacted providers will be receiving
an overpayment letter soon. To assist providers with questions that they may
have relative to these new guidelines, we are providing the following Q&As:
Q: Can I appeal my overpayment?
A: You certainly have the right to appeal any overpayment. However, the
overpayment finding will likely be affirmed since Medicare guidelines do not
allow more than one new patient visit within three years. Medicare also does
not allow payment for a new patient visit billed after an established patient
visit by the same rendering provider.
Q: Can I submit a request to change my new patient visit (that generated the
overpayment) to an established patient visit?
A: Yes, you can submit a reopening request in writing to change your new
patient visit to an established patient visit code if this is the service you
actually performed. In your reopening request, you must tell us the
specific established visit code you want us to change on your claim. You
want to be mindful that there will still likely be an overpayment since
established patient visits typically allow less than new patient visits. You
also want to note that if you choose to bill another new patient visit code
within a three-year period, another overpayment will occur.
Q: I initially billed a claim with an established patient visit in error before
I billed my claim for the initial visit. As a result I received an
overpayment letter. Can I make corrections to both claims?
A: Yes, you can correct both claims. On your first claim which continued the
established patient visit, you can simply call the IVR and request a reopening.
You are only allowed to request a reopening if the claim was processed within
the previous 12 month period. If it has been longer than 12 months, a reopening
should not be submitted.
To correct your second claim, you would need to submit a written request and
indicate the correct procedure that should have originally been billed on your
claim. It is likely that a small overpayment will still be due since
established patient visit codes allow less than new patient visit codes.
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