ED Coding & Reimbursement Alert - 2020 Issue 9
You Be the Coder: Establish the Real Status of These New Patients
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Article Overview
This premium coding Q&A addresses patient status determination for evaluation and management reporting in a practice-change scenario. It is aimed at coders, billers, and physician office staff who need to understand how the general CPT patient-definition guidance applies when a clinician joins a new group but continues seeing individuals previously treated elsewhere. The article discusses the relevant framework at a high level and clarifies the staffing and practice-relationship factors that affect whether a visit is treated as new or established.
Why This Topic Matters
Patient status affects E/M code selection and can change how encounters are reported across physician transitions between practices. Understanding the general rule helps offices avoid inconsistent billing and align documentation review with CPT guidance.
What You Will Learn
- How patient status is evaluated for office E/M reporting in a practice-transition scenario.
- Why prior professional services within a three-year window are relevant to status determination.
- How group practice relationships factor into the general CPT patient-definition framework.
- How offices should think about established-versus-new patient classification when a physician changes organizations.
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Physician office staff
- Compliance personnel
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