What We’re Reading – Medicare E/M claims for new patients

Beginning on October 1, 2013, CMS will use a new claim edit to determine if more than one initial visit code was billed for a Medicare beneficiary within a three year period.   This edit will also identify claims where established visits were billed in advance of the new patient visit. 

Don’t be alarmed if you begin to receive claims denials and/or recoupment letters because of these edits!  There are a few easy solutions to rectify any problems.  If you receive a denial for an initial visit and, upon review, conclude that it should have been billed as an established visit:

  • Use the Interactive Voice Response (IVR) to have the claim reopened;
  • Submit a new claim; or
  • Request in writing to have the claim reopened.

If you have already received recoupment letters regarding these issues, or have any questions about the new edit, please refer back to FCSO’s article.

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