AAPC - Back to school
Results 1 to 6 of 6

Thread: New/Est within same practice

  1. #1

    Default New/Est within same practice

    AAPC: Back to School
    We have a group practice with 3 ENT's and 1 Dermatologist. My Doctors want to see some documentation regarding the guidlines on how to bill new vs established if a patient sees more than one doc in our practice for differant conditions. the three year rule keeps popping up when we code new patient in the following example.
    For example if one of our doctors sees a patient for a ear problem (this doc is ent/neurotology) one year and then the next year sees one of our other Docs for the first time for a thyroid problem can the second doc that treated for the thyroid code a New Patient Exam.
    All of our Docs have the same Group NPI and use the same Tax ID but of course have individual NPI's that appear on the claim.
    If anyone can offer guadiance and also where i can find documentation that would be great.

  2. #2
    Join Date
    Apr 2007


    The best resource is the CPT books Decision Tree for New vs Established Patients under the E/M guidelines.

    It is based on same group/same specialty. So how your providers are credentialed is how you determine new or established.

    It doesn't matter what the issue is they are treating just if they are of the same specialty in the same group.

    Laura, CPC, CEMC

  3. #3


    Thank You!

  4. #4

    Default new vs. est

    can someone advise where i can find medicares guidlines on this matter. My Doctors want to see it. Thank You

  5. #5
    Join Date
    Apr 2007
    North Carolina


    Definition of New Patient for Selection of E/M Visit 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 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.


    Section 30.6.7

  6. #6

    Wink hi ear

    the most recent material is in CODING EDGE October, 2009 and it includes some material that is relavant to levels of E/m. There's a quote from a former medical director of HCFA (ie: CMS) ,,,,
    actually, upon re-reading, I realized that it is focused on the levels that a doctor may bill in cases where the the patient has a 'new' problem...it is still interesting though. Hope I haven't sent anyone chasing geese!

    Last edited by Jamesmmm; 01-13-2010 at 10:36 AM. Reason: new info

Similar Threads

  1. Replies: 3
    Last Post: 12-15-2015, 07:31 AM
  2. New or Est when physician buys practice?
    By Shannonbeth79 in forum E/M
    Replies: 5
    Last Post: 12-16-2011, 11:24 AM
  3. Replies: 1
    Last Post: 12-02-2010, 09:52 AM
  4. New pt or est pt
    By kkerckhoff@alaskaurology.com in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 11-16-2010, 11:11 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.