Radiology Coding Alert

Question: I have trouble keeping up with the little rules about whether a patient is new or established. Is there an easy way to figure this out?


Arizona Subscriber

Answer: The AMA, which publishes the CPT codes, offers these five questions to determine whether you should treat a patient as new or established for E/M coding purposes.

1. Has the patient ever received any professional services from any physician in this group?

No: The patient is "new."
Yes: Go on to question #2.

2. Has the patient received any professional service from a particular physician within the past three years, who is now reporting a service?

Yes: The patient is "established."
No: Go on to question #3.
 
3. Has the patient received any professional service* from a physician in the group of the same specialty, within the past three years?

(*In the context of deciding between new and established, CPT defines a professional service as "those face-to-face services rendered by a physician and reported by a specific CPT code." In other words, just interpreting films doesn't count as a prior professional service because the radiologist wasn't face-to-face with the patient.)

No: The patient is "new."
Yes: Go on to question #4.
 
4. Has the patient received care from a physician  of the exact same specialty within the past three years, or is a physician of a different subspecialty now providing care?

The providing physician is of the same specialty: The patient is "established."
The providing physician is of a different subspecialty: Go on to question #5.

5. Does the current providing physician have the same tax ID as the physician who provided a separate service within the past 36 months?

Yes: The patient is "established."*
No: The patient is "new."

*Medicare allows reporting of new patients for physicians in the same group but of different specialties, such as pulmonology and radiology.)

Note: You can also find a similar flowchart on page 2 of the "Evaluation and Management (E/M) Services Guidelines" portion of the CPT 2007 Professional Edition, published by the AMA.