Using The 3-Year Rule In Your Medical Billing

Using The 3-Year Rule In Your Medical Billing

Did you know that the medical billing rule states that your patient is new if you haven’t seen them for three years? There are usually several questions people have about how to code a semi-established patient. There are some simple medical billing tips to keep in mind when performing this task.

It is a common medical billing mistake to bill for a new patient visit when the patient is merely visiting a different doctor in the same medical practice. The rule states that if you are using the same provider code, then you are considered one entity. Even if the time spent by the “new” doctor is the same duration as a new patient visit, you still need to do medical billing for an established patient. This means that you would use CPT code 99214 instead of 99204. This medical billing rule may mean lower reimbursement, but unfortunately that is just the way it is.

The only time you can use a new patient medical billing code on an old patient is when they have not been seen in your practice for three years or more. In this case, payers will pay for a 99204 code and allow you additional money.

There are several rules you must follow in medical billing. Failure to follow these rules could lead to nonpayment or payer audits. Both of these scenarios are bad for your practice. Hiring a medical billing firm can alleviate some of these responsibilities for you. Medical billing firms keep up to date on new policies, procedures, and codes.

They are highly skilled and make it their mission to give you a profitable medical practice. Medical billing firms understand the three year rule and many more complicated rules your practice may run into.

View all Articles by: Melissa Clark, CCS-P