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Simplify the New or Established Patient Decision

Simplify the New or Established Patient Decision

Many evaluation and management (E/M) service codes distinguish between new or 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 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, or in a facility). The short answer is, wherethe patient is seen doesn’t matter. The June 1999 issue of AMA’s CPT Assistant 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.

By the same logic, if a physician has provided face-to-face services in the hospital, and sees that same patient in his or her office within three years, the patient is established.
Note that 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 might still be new, for instance, if the physician had interpreted test results a month earlier, but had provided no face-to-face 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.

John Verhovshek
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About Has 577 Posts

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 “Simplify the New or Established Patient Decision”

  1. Carolyn McKee says:

    not sure about whether or not to add mod 25 tp new pt visit, I never have but some are saying there are some cases when it’s appropriate. thanks

  2. Donna Buss says:

    Thank you for the information. I do have a question regarding new and established. We have been going back and forth in my office on the correct usage of 90792. We are behavioral health and PCP specialties. Some providers are using the 90793 and then the patient is seeing are PCP and they are using a new patient visit. I believe that we should use the 90791 with a new visit and the 90792 with established patients.
    Can you help clear up how confusion.
    Thank you!

  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?