Three Year Rule Requires Face-to-Face Service

When selecting among E/M codes with “new” and “established” patient categories, most coders know to follow the so-called three year rule. If the provider has seen the patient in the past 36 months, the patient is established.

It’s important to stress that the provider must have seen the patient. The Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7) states:

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.

So, if the provider has performed only a non face-to-face service(s) to the patient in the previous 36 months, a new patient code should be billed. If the patient was seen face-to-face by the provider in the prior three years, select an established patient code (three year rule).

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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