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Practice Management Express Spotlight — Sept. 29, 2013


Recent Rash of RAC Audits

Submitting a new patient exam when it should have been an established patient exam has triggered several of the latest Recovery Audit Contractor (RAC) data driven audits.

CPT clarifies the definition of a new patient: “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

As a reminder:

  • A new patient is one who has never been seen by anyone in the practice ever or within the past three years (1,096 days).
  • Existing patients of the practice should be billed as such, even if the ophthalmologist who performs a particular exam has never seen the patient before (e.g., the retina specialist examines a patient normally seen by the comprehensive ophthalmologist.
  • Existing (prior) patients of a new physician who recently joined the practice should be billed as established patients of the practice because of their prior relationship with the physician. (This applies only to patients seen within three years of their last visit with the ophthalmologist.) Physicians’ National Provider Identifiers (NPI) follow them wherever they practice.
  • Patients from prior referrals must also be billed as an existing patient if the referral appointment occurred within the last three years. For example: Ophthalmologist A sends a patient to ophthalmologist B for a specific test because the ordering ophthalmologist A doesn’t own the equipment. Ophthalmologist B has his/her staff perform the test. If, within three years of the test, the patient decides to see ophthalmologist B for an exam, it should be billed established patient exam should be submitted. While ophthalmologist B didn’t have a face-to-face encounter, he or she previously provided a professional service.


Jennifer Arbuckle, OCS, CPC AAOE —Academy Coding Specialist

Sue Vicchrilli, COT, OCS —Academy Coding Executive