Determine New vs. Established Patient for E/M Coding
Question: Our providers sometimes request that we bill a new patient evaluation and management (E/M) code (99202-99205) when seeing a patient who hasn’t been to our office in a few years, or when the visit occurs at a different clinic location. In other situations, they consider the patient “new” because it’s the first time they’re treating them for a different condition. I want to make sure we’re applying the correct rules when deciding between new and established patient codes. What’s the proper way to determine if a patient is truly “new” under CPT® and Centers for Medicare & Medicaid Services (CMS) guidelines? New York Subscriber Answer: This is a common area of confusion, and getting it right is important for both reimbursement and compliance. According to CPT® and CMS guidelines, a new patient is one who has not received any professional face-to-face services from the physician or any physician of the same specialty in the same group practice within the past three years. This includes not only E/M visits, but also any other face-to-face services, such as procedures, consultations, or hospital visits. Watch out: Many people assume that only a previous E/M visit counts toward determining whether a patient is established, but that’s not correct. Any in-person interaction, such as a minor surgical procedure or inpatient consult, would count as a face-to-face service. For example, if a provider saw a patient in the hospital two years ago and now sees them in the office, the patient is considered established. Similarly, if a patient saw a physician in a different practice setting but of the same specialty within the last three years, they are also considered established — even if it’s their first time at the current location. If a patient follows a provider from one practice to another, that doesn’t reset their status to new. If the same physician has seen them within the past three years, the patient remains established, regardless of location or group affiliation. Also, a patient is not considered new just because they are being seen for a new diagnosis. Patient status is based on the history of face-to-face services with the provider or provider group — not on the medical issue being addressed. Practices that operate from multiple office locations should also avoid assuming patients are new just because they are being seen in a different city or building. If it’s the same group and same specialty, and the patient has been seen within the past three years, they are still established. An exception applies when the patient is seen by a provider of a different specialty in the same group. For example, if a patient sees a cardiologist one year and a pulmonologist the next, those services are considered separate by specialty, so the patient may be considered new to the pulmonologist. Warning: Getting this wrong can have serious consequences. Reporting a new patient E/M code for someone who is actually established is considered upcoding. The Office of Inspector General (OIG) warns against this in its compliance guidelines. If audited, the practice could be required to return overpayments and, in more severe cases, could face civil or criminal penalties for fraud. To avoid mistakes, always check whether the patient has had any face-to-face encounter with the same provider — or a provider of the same specialty in the same group — within the last three years. If so, they’re established, no matter the diagnosis, location, or how long it has been since their last visit. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
