Compliance: Make Distinguishing Between New vs. Established Patient a Breeze

Why This Topic Matters

Correctly distinguishing new versus established patient status affects evaluation and management coding compliance and helps practices avoid billing errors when patients are seen by different physicians, in different settings, or across time within the same group.

Article Sections

1. Tip: Keep track of timelines

   Introduces the time-based framework used to distinguish patient status for office and outpatient evaluation and management visits. It frames the discussion around prior professional services and the relevant lookback period.

2. Turn to CPT® for Guidance

   Summarizes how CPT guidance defines patient status and how that definition applies within a group practice. It also addresses the role of specialty and subspecialty distinctions in the general policy discussion.

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

   Explains how patient status can be affected when care is provided by another physician in the same practice or specialty. The section includes a general example and discusses how subspecialty situations may differ.

4. Avoid Coding Based on Location

   Discusses why the setting where care was provided is not the primary factor in determining patient status. It also addresses how subsequent care across office, outpatient, and hospital settings relates to the broader policy.

5. Pay Attention When Physicians Change Practices

   Covers how patient status is handled when physicians move, when patients follow a doctor to a new location, and when payers evaluate provider identification information. The focus is on the continuity of the patient relationship across practice changes.