New vs. Established Patients: Who’s New to You?

New vs. Established Patients: Who’s New to You?

Billing for new patients requires three key elements and a thorough knowledge of the rules.

A persistent concern when reporting evaluation and management (E/M) services is determining whether a patient is new or established to the practice. New patient codes carry higher relative value units (RVUs), and for that reason are consistently under the watchful eye of payers, who are quick to deny unsubstantiated claims. Here are some guidelines that will ensure your E/M coding holds up to claims review.

Be Sure New vs. Established Applies

Not all E/M codes fall under the new vs. established categories. For example, in the emergency department (ED), the patient is always new and the provider is always expected to get the patient’s history to diagnose a problem.

In the office setting, patients see their provider routinely. The provider knows (or can quickly obtain from the medical record) the patient’s history to manage their chronic conditions, as well as make medical decisions on new problems.

A provider seeing a new patient may not have the benefit of knowing the patient’s history. Even if the provider can access the patient’s medical record, they will probably ask more questions.

What’s New?

The definition of a new patient is listed in the CPT® code book:

A new patient is one who has not received any professional services 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.

In addition to this definition, the Centers for Medicare & Medicaid Services (CMS) adds in Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7):

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.

Define “New”

Let’s break down the three key components that make up the new patient definition:

Professional Service: When physician coders see this, we automatically think of modifier 26 Professional services. This leads us to think that if the provider bills a claim for radiology or labs, and sees the patient face to face, an established patient office visit must be billed. This is not true, per the aforementioned CMS guidance. If the provider has never seen the patient face to face, a new patient code should be billed.

Example: A patient presents to the ED with chest pain. The ED physician orders an electrocardiogram (EKG), which is interpreted by the cardiologist on call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. The patient is sent home and asked to follow up with the cardiologist next week for coronary artery disease. At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, but did not see the patient face to face.

Three-year rule: The general rule to determine if a patient is “new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.

Example: A patient is seen on Nov. 1, 2014. He moves away, but returns to see the provider on Nov. 2, 2017. Because it has been three years since the date of service, the provider can bill a new patient E/M code.

Different specialty/subspecialty within the same group: This area causes the most confusion. For Medicare patients, you can use the National Provider Identifier (NPI) registry to see what specialty the physician’s taxonomy is registered under. For payers, this usually is determined by the way the provider was credentialed.

Those who are part of the credentialing process must understand how important it is to get the provider enrolled with the payer correctly. Denials will ensue if this is not done correctly.

New to Whom?

Problems begin when doctors switch practices, send patients to mid-levels, and cross-cover for each other. Here are some examples of these situations:

If a doctor changes practices and takes his patients with him, the provider may want to bill the patient as new based on the “new” tax ID. This is incorrect. The tax ID does not matter. The provider has already seen these patients and has established a history. He cannot bill a new patient code just because he’s billing in a different group.

If a doctor of medicine (MD) or doctor of osteopathy sends a patient to a mid-level provider (i.e., nurse practitioner (NP) or physician assistant (PA)) and the visit does not fall under incident-to, the NP or PA could bill a new patient code if they are a different specialty with different taxonomy codes. If the MD is a family practice provider and the NP sees hematology patients, for example, the specialty is different and a new patient code can be billed. But if the NP is also considered family practice, it would not be appropriate to bill a new patient code.

If one provider is covering for another, the covering provider must bill the same code category that the “regular” provider would have billed, even if they are a different specialty. For example, a patient’s regular physician is on vacation, so she sees the internal medicine provider who is covering for the family practice doctor. The internist must bill an established patient code because that is what the family practice doctor would have billed.

Know the Exceptions

There are some exceptions to the rules. For example:

Some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to her becoming pregnant.

Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.

Know When to Appeal

If a new patient claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal.



Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7):

Lori Cox

Lori Cox

Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, is coding team leader at MedKoder in Hannibal, Mo. She has more than 15 years of experience in multiple areas of healthcare including auditing and compliance. Cox has been certified since 2002 and is treasurer of the Quincy, Ill./Hannibal, Mo., local chapter. She is the Region 5 AAPC National Advisory Board representative.
Lori Cox

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Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, is coding team leader at MedKoder in Hannibal, Mo. She has more than 15 years of experience in multiple areas of healthcare including auditing and compliance. Cox has been certified since 2002 and is treasurer of the Quincy, Ill./Hannibal, Mo., local chapter. She is the Region 5 AAPC National Advisory Board representative.

8 Responses to “New vs. Established Patients: Who’s New to You?”

  1. Melissa Aikens Conley says:

    I am a medical assistant at a family medical practice . I am wondering if we see a patient for a complete physical using 99396 but the patient sees a different doctor at a different facility for the gynological exam (pap,pelvic and breast exam) also using 99396 will both physicals be a covered service and avoid any out of pocket expense for the patient?

  2. ramu says:

    I have a doubt on New vs estb.
    The Patient seen in ED and had a Ophthalmology consultation with one of optha department Dr for FB in eye than next week patient came to Ophthalmology and seen by other optha physician so for this visit I can consider as establish right.

  3. Barbara Olsen says:

    If a patient switches from a Pediatrician to an Internal Med or Family Practitioner within the same group practice (same tax id, same NPI GRP#, different physical location), would that be a New patient to the Internist or Family Practitioner?

  4. Debra says:

    Great examples! Always great to refresh your memory. Thanks

  5. Lanissa says:

    There is an ongoing discussion in our office regarding this. In our situation – our medical group runs a Walk In Care -(non emergent, staffed by CRNP and PA) they fall under family practice. the visits are mostly acute and do not meet the criteria to bill for new patients so they are billed at 99212 or 99213. However the problem comes when they do come to one of our Family Medicine practices to establish as a new patient and they have a full workup, when we bill the new patient codes, they are all being denied. Does anyone have experience with this?

  6. Pamela Cava says:

    If a patient leaves my practice and goes to see another physician SAME specialty DIFFERENT PRACTICE and then leaves that practice to come back to me within a 3 year period, is that billed as a NEW patient.
    According to AAP billing since it is a different practice the patient would be considered NEW if reestablishing back with you within 3 years

  7. Terry in CA says:

    No that would be an established patient visit. The 3-year rule does not have exceptions. The patient was seen within 3 years. It does not matter that they left and returned. AAP would be incorrect, if that was their interpretation.

  8. hastana rasouly says:

    Does this rule apply to patients with commercial insurance as well?

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