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New vs. Established Patients

  1. #1
    Default New vs. Established Patients
    Exam Training Packages
    Billing for new patients services for office visits are as follows: A new patient is defined as someone who has never been seen by you or a physician in the same specialty in your group OR who has not been seen by you or a physician in the same specialty in your group for at least three years.

    How would you bill for services if the provider is listed under the same specialty i.e. an Ophthalmologist, but treats an established patient under his/her subspecialty. Would this be billed as an established patient or can it be billed as a new patient under the subspecialty? ( The providers are using the same TIN number).

    Please advise


  2. #2
    Kingsport, TN
    Default New or Established
    If you look at the Decision Tree for New vs Established Patients in CPT and follow the questions/answers it appears in your situation, NEW patient would be your answer.

  3. #3
    I'm not sure I understand.

    The patient is established with the provider under one specialty but he is seeing them under a different subspecialty now?

    If it is the same provider it doesn't matter what specialty they are, if that individual has seen the patient within the last 3 years they are established with that provider.

    Now, if they are established with the group under one specialty but are being seen by a different recognized specialty yes the patient would be new. But many subspecialties are not recognized and are treated the same as if they weren't subspecialized.

    Common example is Cardiology and EP. EP is not recognized and is just considered Cardiology.

    Laura, CPC, CPMA, CEMC

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