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Issue Number - Name
0043 - New Patient Visits
Review Type
Automated
Claim Type
Physician/Non-physician Practioner
Region and State
RAC 1-4
All States
Date Approved
2017-03-09

Description

Identification of overpayments made when providers report visits with new patient Evaluation and Management (E/M) codes for patients who do not meet the definition of a new patient. Claims are recouped when a provider bills a new patient visit code and the same provider, or a provider from the same group practice, and with the same specialty has performed any other E/M services within a 3-year period of time.

Affected Codes

  • 3115

Applicable Policy References

  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.A,  Effective date 01/01/2016
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1, Effective date 01/27/2014
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9,  Effective date 01/01/2011
  • AMA CPT Manual, Evaluation and Management Services Guidelines (1999 through present)