New vs. Established: Brush Up on the Basics
Understand new and established patient requirements and how to apply them.
By G.J. Verhovshek, MA, CPC
Most professional coders—even relative beginners—are familiar with the “three-year rule” to determine whether a patient is new or established with a provider. But that familiar rule has a few wrinkles that make determining patient status more complex than you might realize. Even when using the handy Decision Tree for New vs Established Patients in the CPT® codebook’s Evaluation and Management (E/M) Services Guidelines section, you’ll need to know some additional definitions and details to ensure you make the right designation.
Established Patients Mean Face-to-Face Services
CPT® defines an established patient as meeting several requirements simultaneously. Namely:
An established patient is one who has received a professional service 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.
The first requirement is that a patient has received a “professional service.” Solely within the context of E/M code selection, CPT® defines a professional service as “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).”
The important part here is “face-to-face.” Medicare policy (CMS Transmittal R731CP, CR 4032) confirms, “An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”
A patient would still be new, for instance, if the physician interpreted test results for the patient two years earlier, but had not provided the patient a face-to-face service within the previous three years.
New to Whom?
The second requirement addresses patient status relative to other providers in a group practice. A patient is still new to a provider when another provider within the same group practice has seen the patient within the past three years, but that provider is of a different specialty/subspecialty.
For example, a patient consults with an orthopedist for possible hip replacement. The patient has seen an internist in the same group five times in the past three years. In this case, the patient is established for the internist, but new to the orthopedist.
Resource: For a list of Medicare-recognized physician specialties, visit the CMS website.
The flip side of this requirement is that when a patient becomes established with a physician who works in group practice, the patient is established with all physicians of the same specialty/subspecialty in the group. The American Medical Association (AMA) allows an exception for new physician’s seeing a patient established to the practice for the first time. CPT® Assistant, November 2008, features the following Q&A [emphasis added]:
Question: Can new physicians who come on board to a group practice with their own tax identification numbers charge a new evaluation and management code for patients they see?
Answer: According to CPT guidelines, a new patient is one who has received no professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Also, if a physician is new to this group practice and had never seen or billed a patient previously through his tax ID number, this should be considered a new patient for the purposes of this physician billing for his evaluation and management service.
Not all payers agree with this logic; investigate your specific payers’ requirements before billing as “new” any patient who is established with another physician of the same specialty/subspecialty within a group.
Established Encompasses Covering Providers, too
If a provider is on call for, or covering for, another provider, a patient’s status is relative to the provider who is unavailable (not the covering provider). For example, Dr. Smith is covering for Dr. Jones, who is on a family vacation. Patients who are established with Dr. Jones would be treated as established with Dr. Smith, even if Dr. Smith has not seen the patient previously.
Likewise, per CPT® guidelines, “When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same sub-specialties as the physician.”
Patient Status Travels
A common conundrum is how to determine the patient’s status if the provider has seen a patient previously in another location within the past three years. CPT® Assistant (June 1999) explains:
Consider Dr. A, who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr. A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr. A would consider the patient a new patient. However, if Dr. A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr. A.
In other words, where the patient is seen doesn’t matter. If the provider treats a patient face-to-face service within the previous three years (in any location), that patient is established (in all locations).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.