How to bill for glucose monitoring, defining 'new patient,' billing for penicillin shot

Q: Several of our patients with diabetes that is not well-controlled wear an ambulatory continuous glucose monitor several times per month. We have had no success in billing these services, even though the results are interpreted and used to help regulate a patient's disease.

DEFINING 'NEW PATIENT'

A: According to the Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network's MLN Matters number MM6740, revised December 14, 2009: "A new patient is a patient who has not received any professional services ([evaluation/management (E/M)] or other face-to-face service) within the previous three years." If a physician or qualified non-physician practitioner (NPP) has seen the patient in the prior three years, then he or she cannot bill for a new-patient office visit even if the consultation is for a different diagnosis than previously treated.

"Medicare may pay for an [initial] inpatient hospital visit or [a new-patient] office or other outpatient visit if one physician or qualified NPP in a group practice requests an [E/M] service from another physician in the same group practice when the consulting physician has expertise in a specific medical area beyond the requesting professional's knowledge," according to the publication.

Historically, CMS has based such determinations on the existence of different taxonomy codes. If no separate taxonomy code exists to designate a subspecialty, then a new-patient visit cannot be charged if any physician or qualified NPP from the same group has seen the patient in the past three years.

Internal medicine (taxonomy 207R00000X) and nephrology (taxonomy 207RN0300X) have different codes. Therefore, a new patient visit may be charged if the patient has not been seen by another same-specialty provider (nephrologist or internist, depending on the consultation request) within the same group in the past three years. It would be prudent to obtain an opinion from your insurance carrier regarding your ability to charge new-patient visits for non-same-specialty providers within your group.