Medicare E/M Claims On Hold For New Patients

The Centers for Medicare & Medicaid Services (CMS) has identified issues with the implementation of change request (CR) 8165, which has impacted evaluation and management (E/M) claims for new patient visits.

To address these issues, CMS instructed its Medicare administrative contractors (MAC) to hold all claims for Current Procedural Terminology ® (CPT) codes CPT 99201-99205, CPT 99324-99328, CPT 99341-99345, CPT 99381-99387, CPT 92002, CPT 92004. CPT 99211-99215, CPT 99334-99337, CPT 99347-99350, CPT 99391-99397, CPT 92012, and CPT 92014, until the system fixes are in place, November 18, 2013.

Providers should not be adversely affected as this claim hold falls within the current 14-day standard allowed under the law.

As outlined in MM8165 external pdf file, Medicare implemented a common working file system edit to identify claims in which than one new patient visit was billed for the same patient within three years. Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period. This guideline is outlined in 100-04 Chapter 12 Section 30.6.7A.