Outpatient Facility Coding Alert - 2019 Issue 7
Reader Question: Determine New vs. Established by Service, Not E/M
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Article Overview
This article addresses a practical coding question about patient status classification for office and related services. It explains the general CPT and CMS framework for distinguishing new from established patients, why the distinction matters for billing and documentation, and how the discussion applies when a patient has received other professional services in the practice during the lookback period. It is intended for coders, billers, and compliance staff who need to understand how service history can affect patient classification.
Why This Topic Matters
Patient status affects how services are reported and reviewed. Understanding the broader definition of prior professional services helps reduce classification errors and supports consistent coding and documentation practices.
What You Will Learn
- How CPT and CMS define established patient status in general terms
- Why prior professional services can affect patient classification
- How practice-wide service history may be relevant to new-versus-established determinations
- What kinds of documentation history are discussed in relation to the question
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle personnel
- Compliance professionals
- Physician practice managers
Codes Discussed
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