New vs. Established Made Easy

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  • November 13, 2014
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Many evaluation and management (E/M) service codes distinguish between new and established patients. A patient is “new” if he or she has not received a face-to-face, professional service from the provider, or a provider of the same specialty/subspecialty in a group practice, within the previous 36 months. This is commonly known as the “three year rule.”
If another member of the group has seen the patient for a different problem within the past three years, but that provider is of a different specialty/subspecialty, you might still report a new patient service. For instance, a patient consults with an orthopedist for possible hip replacement. The patient saw an internist in the same group practice several times in the past three years. In this case, the patient is new to the orthopedist, but established for the internist.
Tip: For a list of Medicare-recognized physician specialties, check the CMS website.
One common question is how to determine the patient’s status if the provider has seen a patient previously in a different location (such as at another practice). The answer is, where the patient is seen doesn’t matter. 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.

Only face-to-face services count toward a patient’s new or established status. CPT’s® E/M Services Guidelines stress, “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).” A patient is new, for instance, if the physician interpreted test results a month earlier, but had provided no face-to-face services to the patient within the previous three years. CMS Transmittal R731CP, Change Request 4032 affirms this, stating,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.”
Make the right choice, quickly: To determine if a patient is new or established, follow the “Decision Tree for New Vs Established Patients” in the CPT® E/M Services Guidelines.

Evaluation and Management – CEMC

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “New vs. Established Made Easy”

  1. Daizy says:

    I have a question and cant seem to find an answer on the internet. What if an established patient has changed insurances and they come in for an annual visit with this new insurance. Can we bill the patient’s new insurance with a New Patient CPT Code, for example 92004-New PT Eye Exam vs. 92014- Established PT Eye Exam??
    Please and Thank You,

  2. Michelle Simmons, CPC says:

    No, the patient is still established. Just because they changed insurances does not mean they are new.
    Technically you would probably get paid if you billed for a new patient as the insurance does not know you have already seen the patient, however, that is not the ethical way to bill this.
    Patient has already been established with the practice regardless of insurance.
    Hope this helps

  3. Tricia says:

    Hi. We are a multi-specialty physician group. What if a patient is established with a pediatrician in our group and then when they turn 18, they switch over to a different physician within the same group who is internal medicine? Would the internal medicine physician bill as new or established?

  4. GINGER says:

    We have a new orthopaedic surgeon with a different subspecialty at our practice. The patient is already established with a different orthopaedic surgeon for a different problem. Can we charge a new patient office visit for the new doctor because he has a different subspecialty with in 3 years?

  5. Nichole says:

    Hi, I was wondering if this new vs. established rule is the same for FQHC’s? I can’t seem to find anything online to clarify if FQHC’s have different guidelines to follow on determining whether a patient is new or not.

  6. Traci says:

    What if a pt has been seen by a provider for a knee problem and then gets in an MVA and now wants to see that provider for their MVA injuries. Would we bill for a new patient eval for the MVA claims? I would like to think we cannot but I am just verifying this so I can inform a physician that thinks we can.

  7. Jennifer says:

    It sounds like your doctor is mixing up the new/established rules with consult rules. If a doctor consults for a problem and then the patient is later referred to him again for a new problem then the consult codes may be used again for the new problem even though the patient has seen the doctor before.
    This does not apply with new/established patient encounters. If the doctor has seen the patient within the last three years, the encounter will be considered established.

  8. Debbie Flemings says:

    From Medicare’s Specific Payment Codes for the Federally Qualified Health Center Prospective Payment System, an FQHC visit for a new patient is defined as one who has not received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within the past three years prior to the date of service.