“New” or “Established” Status Travels with the Patient
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. One common conundrum is how to determine the patient’s status (new or established) if a provider has seen a patient previously, in another location. 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).