Medicare New Edit - new patient CPT billed two times within three years

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years

Note: This article was revised on June 4, 2013, to reflect the revised CR8165 issued on May 31. The article shows a revised list of new patient CPT codes and an added list of established patient CPT codes on page 2. Also, the CR release date, transmittal number, and the Web address for accessing CR8165 have been revised. All other information remains the same.

Provider Types Affected 

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed 

This article is based on Change Request (CR) 8165 which informs Medicare contractors about changes to Medicare's Common Working File (CWF) system that will detect erroneous billings when there are two new patient Current Procedure Terminology (CPT) codes being billed within a three year period of time by the same physician or physician group.

Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes.

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with "New Patient" Evaluation and Management (E&M) services to have improper payments, because the new patient services have been billed two or more times within a 3-year period by the same physician or physician group. The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that “Medicare interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., 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 3 years. For example, if a professional component of a previous procedure is billed in a 3 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.”

Major steps involved when change of ownership in practice

 Change of Ownership

When an organization having a provider agreement undergoes a change of ownership in accordance with the principles articulated in 42 CFR Part 489 and §3210 of the State Operations Manual, the agreement with the existing provider is automatically assigned to the new owner so that there is no interruption in service.  However, a new agreement with updated information must subsequently be signed and a Form CMS-855A must be submitted by both the old and new owners.  Only if the provider, under the change of ownership, meets the applicable requirements for approval can the agreement be executed.  For FQHCs, these requirements include PHS approval. 

An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medicare program.  A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention. 

A change of ownership occurs, for example, when: 

• A sole proprietor transfers title and property to another party; 

Medicare new patient claim edit and how to appeal on denial ?

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

More than one new patient visit was billed within a three-year period by the same provider or different providers in the same group with the same specialty.

Can we submit paper document along with Electronic claim initial submission to Medicare?

Yes. Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.

PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.

Although PWK ultimately will allow electronic submission of additional documentation, the October implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).

First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.

First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, Billing provider's name and NPI (national provider identifier).

First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).

• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.

PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.