Back to Basics: Pay Attention to 3-Year Rule to Decide Between New vs. Established Codes

Why This Topic Matters

Correctly identifying patient status affects evaluation and management code selection and helps avoid misclassification across office, hospital, and outpatient encounters. The topic is especially relevant when multiple physicians, specialties, or practice locations are involved.

Article Sections

1. Turn to CPT® for Guidance

   Introduces the CPT framework for distinguishing new and established patients and frames the three-year rule as the central standard.

2. Don’t Assume a New Provider Means New Patient

   Discusses how prior professional services within a group practice affect patient status, including considerations involving specialties and subspecialties.

3. Avoid Coding Based on Location

   Explains why the setting or place of service does not determine patient status and addresses how prior care in other locations affects later visits.

4. Pay Attention When Physicians Change Practices

   Covers patient-status issues that arise when physicians move, when patients change doctors within a practice, and when insurers review provider identifiers.