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New Patient vs Established Patient - debate regarding

  1. #1
    Default New Patient vs Established Patient - debate regarding
    Medical Coding Books
    I have been engaged in a debate regarding the designation of "new" patient status with a few co workers.

    The easiest way to explain my question is to put in an example scenario or three:

    1. Patient Tom Smith is a patient with Dr. Bolin, PCP. Dr. Bolin is an independent practitioner under his own Tax ID of 34-8888881. Patient Smith sees Dr. Bolin every 6 months for his hypertension. He has been a patient here for the past 10 years. Dr. Bolin decides he does not want to be independent anymore and becomes an employed physician with Catholic Healthcare. They purchase his office, assets and all. He and his staff are now employees of Catholic Healthcare under Tax ID 34-0000002. Its now time for Patient Smith to come into the office for his 6 month visit. This is the first time he has been in the office since Dr. Bolin became employed with Catholic Healthcare. Is he considered a "New" or "Established" patient? Why?

    2. Patient Fred Jones is has no Primary Care Physician. Patient Jones becomes ill and needs to see a physician, but it is 8pm and all the physician's offices are closed. Patient Jones decides to go to the urgent care down the street that is owned by Catholic Healthcare. The physicians at the urgent care are employed by Catholic Healthcare. Patient Jones is seen by Dr. Alice. Patient receives antibiotics and is told to follow up in 7 days with a PCP of his choice. Since Dr. Alice does not have a PCP practice and only works at the urgent care, patient Jones asks for a list of local providers. The list has Dr. Bolin on it, who is also employed by Catholic Healthcare. Patient Jones calls the office the next morning and gets an appt for next week. Patient Jones goes to Dr. Bolin's office for his urgent care follow up and to establish as a patient with Dr. Bolin. This is the first time Patient Jones has seen Dr. Bolin. Is patient Jones a "New" or "Established" patient since Dr. Jones and Dr. Alice (urgent care provider) are both employed by Catholic Healthcare. Why?

    3. Scenario #2 can also be asked for patients being seen in the ED or as an inpatient who see the Catholic Healthcare employed "Hospitialist" at the hospital facility then follows up and establishes with Dr. Bolin. "New" or "Established"? Why?

    Any guidance on this subject would be greatly appreciated.

    Thank you,

  2. #2
    New Windsor, New York
    Default #1 established, #2 and 3 New
    Per CPT guidelines, a new patient "is one whou has not recieved any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years."

    Employer and/or Tax ID do not matter. What does matter is if the physician has seen the patient, and in your scenarios, the doctor has previously seen the patient in #1, so he is established. The follow-up visits in #2 and #3 are not with the same physician, only a physician with the same employer, so if this is the first time the patient has seen that follow-up physician, that is a new patient.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

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