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.

These new system edits were turned on October 1. A large number of paid claims have been identified as overpayments due to the above guidelines. As a result, First Coast Service Options Inc. (First Coast) has initiated recoupment of improper payments related to these claims. The impacted providers will be receiving an overpayment letter soon. To assist providers with questions that they may have relative to these new guidelines, we are providing the following Q&As:

Q: Can I appeal my overpayment?
A: You certainly have the right to appeal any overpayment. However, the overpayment finding will likely be affirmed since Medicare guidelines do not allow more than one new patient visit within three years. Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.

Q: Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit?

A: Yes, you can submit a reopening request in writing to change your new patient visit to an established patient visit code if this is the service you actually performed.  In your reopening request, you must tell us the specific established visit code you want us to change on your claim.  You want to be mindful that there will still likely be an overpayment since established patient visits typically allow less than new patient visits. You also want to note that if you choose to bill another new patient visit code within a three-year period, another overpayment will occur.


Q: I initially billed a claim with an established patient visit in error before I billed my claim for the initial visit.  As a result I received an overpayment letter.  Can I make corrections to both claims?

A: Yes, you can correct both claims. On your first claim which continued the established patient visit, you can simply call the IVR and request a reopening. You are only allowed to request a reopening if the claim was processed within the previous 12 month period. If it has been longer than 12 months, a reopening should not be submitted.

To correct your second claim, you would need to submit a written request and indicate the correct procedure that should have originally been billed on your claim. It is likely that a small overpayment will still be due since established patient visit codes allow less than new patient visit codes.