Patients of a New Physician – Established or New?

By Brandi Tadlock, CPC, CPC-P, CPMA

As physicians leave solo practices and other groups to join your group, they bring their patients with them. Are these patients new or established?

If it’s a single-specialty practice and the physician has seen the patient within the last three years – even if he or she has a different tax ID number than the clinic – the patient is billed using the established evaluation and management (E/M) codes (99211-99215).

Why? According to the American Academy of Family Practice (AAFP), although the physician is new to the group, he or she has been providing professional services to the patient within the last three years. When the patient transferred medical records to the new office is irrelevant, the AAFP says. All that matters is when the provider last saw the patient.

AAFP says a patient who does not transfer his or her care to the new group, and who is seen by another physician in the original group practice, is also established if a physician of the same specialty saw the patient within the last three years.

If the patient follows her doctor to the new group, but chooses to see a physician of a different specialty or sub-specialty within the new group, the patient is “new” as long as that physician hasn’t seen the patient within the previous three years. The patient is seeing someone new in a different specialty, rather than a provider within the same specialty who would correctly report the patient as established.

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