How to Determine New vs. Established Patient Status
There’s more to knowing the three-year rule to make the right designation.
Many evaluation and management (E/M) code categories differentiate between services provided to new patients versus those provided to established patients. Here’s what you need to know to determine a patient’s “new vs. established” status.
Only Face-to-face Services
Count to Establish a Patient
CPT® defines an established patient as “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 in the above definition is that the patient has received a “professional service.” 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)” [emphasis added]. MLN Matters® MM4032 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” [emphasis in the original].
In other words, if a provider interprets a patient’s test results, but does not provide a face-to-face service, the patient is not established to that provider.
Determining Patient Status
in a Group Practice
Just because a patient is established with one provider in a group office does not mean the patient is established with all providers in that practice. If another provider within the group practice has seen the patient within the past three years, but that provider was of a different specialty/subspecialty, report a new patient service.
For example, a patient consults with an orthopedist about 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 to the internist, but new to the orthopedist.
When a patient becomes established with a provider in a group practice, the patient is established with all physicians of the same specialty/subspecialty in that group. The American Medical Association (AMA) allows an exception for new physicians seeing for the first time a patient established to the practice. 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 though 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. If a patient is established with another physician of the same specialty/subspecialty within a group, investigate your specific payer’s requirements before billing a patient as “new.”
Patient Status Doesn’t
Change for “On Call” Providers
If a provider is on call for another provider, a patient’s status is relative to the unavailable provider (not the covering provider). For example, Dr. Anderson is covering for Dr. Bradley, who is on medical leave. Patients who are established with Dr. Bradley are (for coding and billing purposes) established with Dr. Anderson, even if Dr. Anderson has not seen the patient previously.
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 subspecialties as the physician.”
Location Doesn’t Affect
New or Established Status
Where the patient is seen has no bearing on status. If a provider furnished a face-to-face service to a patient within the previous three years (in any location), that patient is established to that provider (in all locations). 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.
Tip: For a quick and easy way to determine patient status, see the “Decision Tree for New vs. Established Patients” in the Evaluation and Management (E/M) Services Guidelines of your CPT® codebook.
MLN Matters® MM4032: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm4032.pdf
For a list of Medicare-recognized physician specialties, visit the CMS website: www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/taxonomycrosswalk.pdf
CPT® Assistant, November 2008 and June 1999