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Thread: Sports Physical-New vs. Established

  1. #1

    Default Sports Physical-New vs. Established

    AAPC: Back to School
    A new patient came into the office for a sports physicial. We have a very difficult time getting these reimbursed by insurance, so we normally make these types of visits self-pay.

    If the patient was new and we performed a sports physicial that we made self-pay and nothing went to insurance, and the patient returned a few months later for an unrelated encounter (different problem), would we code this as new or established?

    Providers think established, but I'm leaning towards new since we have not billed an E/M for the sports physical.

    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007

    Default Established

    While you could get paid by insurance without any problems for a new visit, that would not be the correct way.

    CPT does not specify who has to pay for the service when defining new vs est. They just state that a new patient has not received any professional services from the physician or another physician of the same specialty in the same group practice.

    So even though insurance didn't pay for it, there were professional services provided.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

  3. #3


    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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