This policy describes the appropriate use of new patient evaluation and management (E/M) codes.
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1 Private Property of Florida Blue. This payment policy is Copyright 2017, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of Florida Blue. The medical codes referenced in this document may be proprietary and owned by others. Florida Blue makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. PAYMENT POLICY ID NUMBER: Original Effective Date: 12/22/2009 Revised: 06/15/2017 New Patient Visits THIS PAYMENT POLICY IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS PAYMENT POLICY APPLIES TO ALL LINES OF BUSINESS AND PROVIDERS OF SERVICE. IT DOES NOT ADDRESS ALL POTENTIAL ISSUES RELATED TO PAYMENT FOR SERVICES PROVIDED TO FLORIDA BLUE MEMBERS AS LEGISLATIVE MANDATES, PROVIDER CONTRACT DOCUMENTS OR THE MEMBER S BENEFIT COVERAGE MAY SUPERSEDE THIS POLICY. DESCRIPTION: This policy describes the appropriate use of new patient evaluation and management (E/M) codes. REIMBURSEMENT INFORMATION: A new patient is one who has not received any professional services from the physician or another physician and/or health care professional of the same group practice and same specialty, within the past three years. Therefore, a physician or eligible health care professional should only bill for new patient services when the elements of this definition are met. If the definition is not met, the services should be reported with the appropriate established patient code. For purposes of this policy, professional services would include any E/M service or other face-to-face service (e.g., surgical procedure). When a physician is on call for or covering for another physician, the patient s visit will be classified as it would have been by the unavailable physician. The new patient definition applies even if the physician saw the patient while a member of a different physician group. For example, a physician leaves group practice A to join group practice B. If a patient who received professional services while the physician was a part of Page 1 of 5
2 group A sees the physician after joining group B within the three year window, the encounter would be reported with an established patient code. For a listing of specialties as defined by Florida Blue and used for application of this policy see the following link: FB Specialty Listing BILLING/CODING INFORMATION: The following codes may be used to describe new patient encounters: CPT /HCPCS Coding Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or presenting problem(s) are self-limited or minor. Physicians typically spend 10 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are family s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes Office or other outpatient visit for the evaluation and management of a new patient, comprehensive examination; medical decision making of moderate complexity. family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes Office or other outpatient visit for the evaluation and management of a new patient, comprehensive examination; medical decision making of high complexity. family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem Page 2 of 5
3 focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20 minutes with the patient and/or family or caregiver Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are family s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver Domiciliary or rest home visit for the evaluation and management of a new patient, comprehensive examination; and medical decision making of moderate complexity. family s needs. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes with the patient and/or family or caregiver Domiciliary or rest home visit for the evaluation and management of a new patient, comprehensive examination; and medical decision making of high complexity. family s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes with the patient and/or family or caregiver Home visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or presenting problem(s) are of low severity. Physicians typically spend 20 minutes Home visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. family s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes Home visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of Page 3 of 5
4 the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes Home visit for the evaluation and management of a new patient, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or presenting problem(s) are of high severity. Physicians typically spend 60 minutes Home visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an ordering of laboratory/diagnostic procedures, new patient; 65 years and older S0610 S0620 Annual gynecological examination, new patient Routine ophthalmological examination including refraction; new patient Page 4 of 5
5 DEFINITIONS: New Patient Patient who has not received any professional services from the physician or another physician and/or health care professional of the same group and same specialty, within the past three years REFERENCES: 1. American Medical Association, Current Procedural Terminology (CPT ), Professional Edition 2. Centers for Medicare and Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 12, Physician/Non-Physician Practitioners, Section Found at: Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 3. Family Practice Management, Understanding When to Use the New Patient E/M Codes. September Found at GUIDELINE UPDATE INFORMATION: 12/22/2009 Originally published 08/21/2012 Revised Name updated to Florida Blue 09/01/2014 Revised References updated, Reimbursement information clarified 04/25/2015 Added list of specialties 04/01/2016 Updated link to list of specialties 06/16/2016 Annual Review no changes 06/15/2017 Annual Review adding procedures S0610 & S0620 Private Property of Florida Blue. This payment policy is Copyright 2017, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of Florida Blue. The medical codes referenced in this document may be proprietary and owned by others. Florida Blue makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 (American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Page 5 of 5
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Private Property of Florida Blue. This payment policy is Copyright 2017 Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission
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