AMA CPT® Assistant - 2009 Issue 8 (August)
New vs Established Patient, Decision Tree Explanation (August 2009)
August 2009 page 5 Evaluation and Management:New vs Established Patient, Decision Tree Explanation The Evaluation and Management (E/M) Decision Tree, first printed in the 1999 CPT Assistant and then printed in the 2007 CPT codebook, was revised in 2008 to assist in determining whether to report an E/M service provided as a new or established patient encounter. This article provides clarification regarding how the Decision Tree should be interpreted when E/M codes are reported by the physician, and when appropriate, by the qualified health care professional to describe the services he or she provides to the patient regardless of...
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Article Overview
This CPT Assistant article reviews the Evaluation and Management decision tree and how it is used to distinguish new versus established patient encounters. It discusses the role of physician and qualified health care professional services, the effect of same-group specialty and subspecialty considerations, and why payer policies may influence reporting and reimbursement practices. The article is relevant to coders, billers, compliance staff, and clinicians who report E/M services.
Why This Topic Matters
Accurate new-versus-established patient determination affects E/M reporting consistency and can influence claim submission and reimbursement outcomes. The article also highlights that payer-specific policies may differ from CPT guidance, making it useful for organizations that need to align coding practices with both CPT and third-party requirements.
Article Sections
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Interpreting the E/M Decision Tree
Explains the general framework for using the decision tree to distinguish between new and established patient encounters. It also discusses the role of recent professional services and group specialty considerations.
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Updated E/M Decision Tree
Describes revisions to the decision tree and the removal of certain terminology from the earlier version. It also addresses how broader payer guidance may affect interpretation and reporting.
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E/M Services Affected by the Decision Tree
Identifies categories of Evaluation and Management services that are associated with the new-versus-established patient distinction. It summarizes the types of service groups referenced in the article.
What You Will Learn
- How the E/M decision tree is used at a high level
- Which provider and group relationships are discussed in relation to patient status
- Why payer policies may affect reporting of new and established patient visits
- Which broad E/M service categories are associated with the decision tree
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Physicians
- Qualified health care professionals
Code Ranges Discussed
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