Find-A-Code Focus Newsletter

Q&A: What is the difference between a new and established patient, for office E/M coding purposes?

January 27, 2016



One of my top questions asked at my billing courses.

Question: 
What is the difference between a new and established patient, for office E/M coding purposes? I’ve heard that you can consider a patient new even if they’ve been to your practice before. Is that true?

Answer: If the physicians or other qualified health care professionals in your practice see a patient for the first time ever, you should choose a new patient E/M code (99201-99205Office or other outpatient visit for the evaluation and management of a new patient …). There are also times when you can consider a patient “new” even if she’s been a patient at your practice before.

A key factor in determining whether a patient is new or established is time. You must decide whether any of your physicians or qualified health care professionals has seen the patient in the past, and if you have, how long ago. According to Wisconsin Physician Services (WPS), a Medicareadministrative contractor, a new patient “has not received any professional services from the physician within the previous three years. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”

This definition generally follows the CPT® definition, which states, “A new patient is one who has not received 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.” For CPT® purposes, “professional services” are “face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT® code(s).”

For coding purposes, an established patient “has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years,” states WPS.Again, this is consistent with the CPT® definition, which states, “An established patient is one who has received 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.”

How it works: Let’s say oral surgeons A and B both work for your group practice. Oral surgeon A evaluates the patient in July 2013 for TMJ problems. You report the evaluation of the patient with a new patient office code (99201-99205Office or other outpatient visit for the evaluation and management of a new patient…). In May 2015, the patient returns to the practice with similar problems of the TMJ affecting the joint on the other side. Due to some reasons, the patient is unable to be evaluated by oral surgeon A and oral surgeon B evaluates the patient.

For the 2015 visit, you should choose an established patient E/M code (99211-99215Office or other outpatient visit for the evaluation and management of an established patient …) even though oral surgeon B is seeing the patient for the first time. If the patient was being evaluated by either oral surgeon A or B after a gap of three years, you can report a new patient code for the evaluation.

Potential exceptions: If your practice includes sub-specialists, and the payer allows it, some situations might arise in which new patient E/M codes are appropriate for an otherwise established patient.Also, in some situations in which it is technically correct to use a new patient code, you may want to report the encounter as an established patient visit for the purposes of patient relations. The typical patient will not be familiar with the technical definitions of “new” and “established” discussed above and may still consider him or herself established to the practice, even if he or she is seeing a sub-specialist or it has been more than three years between visits. In such situations, good patient relations may necessitate using an established patient visit code, especially if a new patient visit code will involve greater cost sharing on the part of the patient.

Best bet: Look before you leap. Contact your payers and ask how they apply new and established patient guidelines — specifically with regard to different specialties and sub-specialties in the same group practice



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