Medicare Compliance & Reimbursement - 2010 Issue 6
Reader Questions: Clarify 'New' Versus 'Established' Patient
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Article Overview
This reader Q&A addresses a common E/M coding issue: how to determine new versus established patient status when a patient has already had prior services with a practice, group, or specialist. It is relevant to coders, billers, clinicians, and practice staff who need to apply AMA-based guidance consistently when selecting office and other face-to-face evaluation and management services. The article focuses on broad patient-status rules, practice/group considerations, and timing concepts used in routine coding review.
Why This Topic Matters
Patient status affects evaluation and management code selection and can influence how a visit is reported. Understanding the general rule helps practices apply consistent documentation and coding workflows when prior services were performed by someone in the same organization or specialty.
What You Will Learn
- How patient status is generally determined for E/M coding
- How prior services within a practice or group can affect patient classification
- How timing and encounter type relate to new versus established status
- How specialty and group-number considerations factor into status determinations
Who Should Read This
- Medical coders
- Billing staff
- Physician practices
- Surgeons and other clinicians
- Compliance teams
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