CMS Makes Payment Processing Edit to Reduce Erroneous New Patient E&M Charges

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In order to avoid erroneous billing practices for “New Patient” Evaluation and Management services, CMS issued Change Request 8165 which informs Medicare contractors about changes to Medicare’s Common Working File system that detects errors in billing.  According to Medicare manuals, “New Patient” is defined as: 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.  The changes to Medicare’s Common Working File system will prompt CMS contractors to validate that there are not two new patient codes being paid within a 3-year period of time.  The codes that will be checked as part of the new edit include: 99201-99205, 99218-99223, 99304-99306, 99324-99328, 99341-99345, 99381-99387, 99460-99461, 99468, 99471, 99475, 99477, G0245, G0402, and G0344.  When a new patient codes has been paid more than one time is a 3-year period to the same physician for the same patient, Medicare contractors will consider this an overpayment and recoupment will occur.  If the improper code is identified prior to payment of a second claim, the second claim will be rejected.

These changes come as a result of CMS Recovery Auditors identifying claims where new patient services have been billed two or more times within a 3-year period by the same physician or physician group.  The effective date of Change Request 8165 is October 1, 2013 with an implementation date of October 7, 2013.

The attorneys at Nicholson & Eastin, LLP are available to assist provider with any overpayment issues or with defending Medicare and Medicaid audits and prepayment reviews.