Understanding E/M: New or established? Make sure you know the rules before CMS edits begin in July

Why This Topic Matters

New-versus-established patient mistakes can affect reimbursement, create avoidable denials, and increase audit or compliance risk once payer edits are active.

Article Sections

1. Introduction to the new/established patient issue

   Introduces the upcoming claims edit and frames the overall importance of correct patient-status selection for E/M reporting.

2. How the established patient concept works

   Summarizes the general CPT-based framework used by payers to determine patient status over time and across providers in a practice.

3. Educate staff to stop lost revenue

   Discusses the operational and revenue impact of patient-status errors and the need to train staff when physician rosters change.

4. Scenario 1

   Presents a specialty-and-practice-based example involving prior patient contact and later office follow-up.

5. Scenario 2

   Presents a first-visit example involving a different specialty within the same practice setting.

6. Scenario 3

   Presents a situation involving a physician change of practice and follow-up care by another clinician in the new practice.

7. Scenario 4

   Presents an emergency department encounter followed by office follow-up with a different specialty involved.

8. Scenario 5

   Presents a later encounter in a new practice after the physician has changed practices and time has elapsed since the prior service.