Medicare Compliance & Reimbursement - 2023 Issue 11
Back to Basics: Nail Down the Rules for New Vs. Established Patients
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Article Overview
This article explains how to think about new-versus-established patient status in everyday E/M coding scenarios. It focuses on the CPT guidelines, Medicare guidance, specialty and practice considerations, and situations involving multiple providers or practices. The piece is aimed at coders, billers, compliance staff, and clinic administrators who need a practical understanding of patient classification issues.
Why This Topic Matters
Correct patient classification affects E/M reporting accuracy, compliance risk, and how visits are categorized across providers, specialties, and practices. The article is relevant for organizations trying to apply consistent rules when patients move between clinicians or settings.
Article Sections
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Understand Why the Categories Exist
Explains the general importance of distinguishing patient status and discusses why the distinction affects billing and compliance. It also references E/M service coding under CPT and Medicare.
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Rely on TIN Versus Taxonomy Codes
Discusses how group billing arrangements, specialties, and taxonomy information factor into determining patient status across providers in the same practice. The section uses oncology examples to illustrate the issue.
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Count on the Medicare Non-Face-to-Face Rule
Reviews Medicare guidance on services that do not involve face-to-face encounters and how those services affect patient classification. It also references the Medicare Claims Processing Manual and related CPT concepts.
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Do This When Patients Follow Providers
Addresses situations in which a patient moves from one practice to another and how that affects patient status for Medicare and other payers. The section discusses practice transitions and payer differences.
What You Will Learn
- How new versus established patient status is discussed in CPT and Medicare contexts
- What factors are considered when providers share a group billing arrangement
- How specialty and taxonomy information can affect patient classification
- How non-face-to-face services are treated in Medicare guidance
- How patient status may be viewed when a patient follows a provider to another practice
Who Should Read This
- Medical coders
- Billers
- Compliance staff
- Practice managers
- Physician office administrators
- Revenue cycle professionals
Codes Discussed
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