Medicare Compliance & Reimbursement - 2019 Issue 5
Reader Question: Establish These 3 Rules for New Patient Determination
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Article Overview
This reader Q&A reviews guidance on patient status determination in CPT-related evaluation and management coding. It focuses on the broad factors that can affect whether a patient is treated as new or established, including the nature of prior services, whether they were face-to-face, and whether care occurred in the same specialty or subspecialty. The article is aimed at coders, billers, and practice staff who need to understand how audit findings may arise from patient classification rules.
Why This Topic Matters
Patient status affects E/M code selection and can drive audit outcomes, so understanding the general framework helps practices evaluate records consistently and avoid classification errors.
Article Sections
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Question
A coding audit scenario involving patient classification is presented, with a question about why a visit was treated differently than expected.
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Answer
The response summarizes the general CPT framework for distinguishing new and established patients and outlines the broad categories of services and provider relationships involved.
What You Will Learn
- How patient status is generally discussed in CPT-related coding guidance
- Why the character of prior services can affect patient classification
- How specialty and subspecialty context can influence audit review
- What types of provider interactions are relevant to new-versus-established determinations
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Practice managers
- Physician office staff
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