Wiki New vs Established Patient


Reno, NV
Best answers
I understand the general rules for new vs. established patient. I am unclear as to whether the place of service matters. For example: A specialist rounds on a patient admitted to the hospital, or is called in for a consult in the E/R. When that patient follows up in the specialists office after release from the hospital, is that considered a new patient or an established patient? The first time this patient saw the specialist was in the hospital.
If the patient was seen in the hospital and then presents to the office, (within 3 years) then they are an established patient. The following is copied directly from I hope you find it helpful.

"Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three 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 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. The AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 ( You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.