Part B Coding Coach: Navigate the New-Versus-Established-Patient Maze With Expert Tips

Why This Topic Matters

Correctly identifying patient status and the applicable E/M framework is essential for accurate reporting, compliance, and avoiding inappropriate level selection across multiple settings.

Article Sections

1. 3 Year Rule Determines Patient Status

   Explains the general framework used to determine whether a patient is treated as new or established based on prior encounters within a practice. The section also addresses the role of practice structure and encounter type.

2. Exceptions Could Occur for Different Specialties

   Covers situations in multi-specialty practices where encounters with different specialties may affect patient status for E/M reporting. The section focuses on broad specialty-based distinctions.

3. Consult Codes Don’t Differentiate

   Discusses consultation coding in relation to new and established patient status and summarizes the general documentation framework used for those services. It also references CPT ranges and related service categories.

4. 2 of 3 Will Do for Most Established E/M Visits

   Reviews the general documentation framework for established patient E/M services and how service levels are determined across common outpatient and facility settings. The section includes broader discussion of related CPT service categories.

5. Watch for Overcoding

   Addresses the relationship between documentation, medical necessity, and E/M level selection. It also notes alternative time-based reporting concepts at a general level.