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.”

As a result of overpayments for new patient E&M services that should have been paid as established patient E&M services, CMS will implement changes to the CWF to prompt CMS contractors to validate that there are not two new patient CPTs being paid within a three year period of time.

The new patient CPT codes that will be checked in these edits include 99201-99205, 99324-99328, 99341-99345, 99381-99387, 92002, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012, and 92014). If Medicare discovers that a new patient code has been paid more than one time in a 3-year period to
the same physician, then Medicare contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.