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vdyer

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Hello. I have a question if the patient would be considered new or established. The patient had a PFT done let's just say, Sept, 2025. The provider read the PFT (did not see the patient). Then, the patient was seen in Feb, 2026 by a provider of the same group in which the first provider read the PFT. I thought that this should be considered an established patient (since a provider from the same group previously read the PFT), but I'm kind of getting some backlash and wanted to get others opinion. I have tried to look this up but would like to have something definitive. Thanks!
 
The patient would be considered an established patient according to the E&M guidelines in the CPT manual, assuming the provider the patient is seeing is of the same specialty and subspecialty as the provider who did the PFT reading. The guidelines state the following:
1771009150618.png

I snipped this out of the online version of the CPT manual, if you are looking at a physical book you should find this information in the guidelines as well. You can show whoever is pushing back on you about considering the patient an established patient.
 
CBLENNIE said:
The patient would be considered an established patient according to the E&M guidelines in the CPT manual, assuming the provider the patient is seeing is of the same specialty and subspecialty as the provider who did the PFT reading. The guidelines state the following:
View attachment 8349

I snipped this out of the online version of the CPT manual, if you are looking at a physical book you should find this information in the guidelines as well. You can show whoever is pushing back on you about considering the patient an established patient.
Click to expand...
Thank you VERY much!
 
Respectfully disagree. You are missing the FACE-TO-FACE part. If all they did was read/interpret a report, and did not see/meet the patient face-to-face, patient is new.
See the decision tree and * note here: https://www.aapc.com/blog/51560-nav...Dt5tfP53u8qCEwkftKkv88eKTSXNdjaYy05LC8CQN600E

Further info: https://codingintel.com/new-versus-established-patient-visits/


30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215)
(Rev. 13316; Issued: 07-24-25; Effective:01-01-25; Implementation: 08-25-25)
A. Definition of New Patient for Selection of E/M Visit Add-On Code
• Interpret the phrase “new patient” to mean a patient who has not received any professional
services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the
physician or physician group practice (same physician specialty) within the previous 3 years.
For example, if a professional component of a previous procedure is billed in a 3-year time
period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with
the patient is performed, then this patient remains a new patient for the initial visit. An
interpretation of a diagnostic test, reading an x-ray or electrocardiogram (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.
 
amyjph said:
Respectfully disagree. You are missing the FACE-TO-FACE part. If all they did was read/interpret a report, and did not see/meet the patient face-to-face, patient is new.
See the decision tree and * note here: https://www.aapc.com/blog/51560-nav...Dt5tfP53u8qCEwkftKkv88eKTSXNdjaYy05LC8CQN600E

Further info: https://codingintel.com/new-versus-established-patient-visits/


30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215)
(Rev. 13316; Issued: 07-24-25; Effective:01-01-25; Implementation: 08-25-25)
A. Definition of New Patient for Selection of E/M Visit Add-On Code
• Interpret the phrase “new patient” to mean a patient who has not received any professional
services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the
physician or physician group practice (same physician specialty) within the previous 3 years.
For example, if a professional component of a previous procedure is billed in a 3-year time
period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with
the patient is performed, then this patient remains a new patient for the initial visit. An
interpretation of a diagnostic test, reading an x-ray or electrocardiogram (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.
Click to expand...
Thank you!
 
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