Wiki New Patient Documentation

[rthomas@impcna.com]

Should the documentation of an office note indicate if a patient is new? My established providers document if the patient is new to group in either the Chief Complaint or HPI. ie: Patient present as a new patient for refills on blood pressure medicine but my newer providers do not. I thought I read somewhere that this was required. I always like to have something to back myself up when bringing up documentation requirements. If this is something the providers need to document does anyone have a reference?

 

[TThivierge]

Hi
Yes the provider needs to mention if new or established pt. due to differ evaluation mgnt. CPT code selected. Look at pages 4 and 13 in CPT manual yr. 2023.
Well hope this data helps you provider need to document this when treat pt.
Lady T

 

[thomas7331]

Should the documentation of an office note indicate if a patient is new? My established providers document if the patient is new to group in either the Chief Complaint or HPI. ie: Patient present as a new patient for refills on blood pressure medicine but my newer providers do not. I thought I read somewhere that this was required. I always like to have something to back myself up when bringing up documentation requirements. If this is something the providers need to document does anyone have a reference?

In my experience, payers will judge whether or not a patient is established based on the existing medical record and claims history which, if reviewed, would show whether or not the patient had been treated by the provider within the last three years. It shouldn't be necessary for the provider to state explicitly whether or not the patient is new or established in the text of each note.