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  • 1.  Not necessarily- especially with CMS, which is who I was referring to-

    Posted 03-10-2026 15:32

    I grabbed one of the regional Medicare Carriers rule on this- it is defined by being a new patient in the last 3 years FOR THE PHYSICIAN GROUP, which is in turn defined by the tax ID-

    "New Patient
    Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same 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., lab interpretation) 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. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an
    E/M
     service or other face-to-face service with the patient does not affect the designation of a new patient.
    If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty at a location where the first physician also practices, this is also an established patient situation."


    so it will be quite variable- the individual answers we get at our home institution or group are reflecting how the practice has been structured and therefore how many tax ID's are used, and if multiple at which level of division they are unique.


  • 2.  RE: Not necessarily- especially with CMS, which is who I was referring to-

    Posted 03-10-2026 15:39
    Yes, I know, the issue is " physician group practice (same physician specialty)." You can be in a multi-specialty group, such as all of JHU is under one tax ID, but patients established with neurosurgery are not established with ophthalmology if they haven't seen ophthalmology before. We just went through this with legal, optometry is different than neurology and is different than ophthalmology, even all within Wilmer / JHU

    It has more to do with your billing and compliance office's preference and tolerance for audits / rejections than any actual legality.





  • 3.  RE: Not necessarily- especially with CMS, which is who I was referring to-

    Posted 03-10-2026 15:43
    In a related question, I’ve never used the CPT code 99358 “...used to report the first hour of prolonged, non-face-to-face evaluation and management (E/M) services provided on a date other than the face-to-face encounter. It covers time spent on extensive record reviews, care coordination, or phone calls related to a patient's care.”

    Is this in use, successfully, by anyone in our specialty? I, and I’m sure all of use, do considerable non face-to-face time before and after seeing a patient, in the form of records review, imagine review, telephone calls, etc.

    Mitch


    Original Message


  • 4.  RE: Not necessarily- especially with CMS, which is who I was referring to-

    Posted 03-10-2026 15:45
    Your last sentence is the truth Drew, many regional carriers and especially practice plan adminstrators interpret this to either their financial advantage (lets pay out less) or due to their fear of audit, even when the coding would be correct.  To be more precise, 


    30.6.5 - Physicians in Group Practice
    (Rev. 1, 10-01-03)
    Physicians in the same group practice who are in the same specialty must bill and be paid as though 
    they were a single physician. If more than one evaluation and management (face-to-face) service is 
    provided on the same day to the same patient by the same physician or more than one physician in 
    the same specialty in the same group, only one evaluation and management service may be reported 
    unless the evaluation and management services are for unrelated problems. Instead of billing 
    separately, the physicians should select a level of service representative of the combined visits 
    and submit the appropriate code for that level.
    Physicians in the same group practice but who are in different specialties may bill and be paid
    without regard to their membership in the same group.

    So, if structured properly, and your administration allows, you may be able to bill a new when a cornea person sees them first (on a different day).  But there is a lot of institution/practice specific culture that you must be aware of and wade through first.




    Original Message


  • 5.  RE: Not necessarily- especially with CMS, which is who I was referring to-

    Posted 03-10-2026 15:48
    I think your cleanest scenario would be if a neurologist sees them within the context of an ophthalmology group. However, even in this scenario it would still probably require some billing group education, and your mileage may still vary for the reasons discussed above already by many. 



    Original Message


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