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.”
