Coding Corner: The ins and outs of new vs. established

April 01, 2013
Area(s) of Interest: Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, MA, CPC. Mr. Verhovshek is the managing editor for AAPC, a training and credentialing association for the business side of health care.

Many evaluation and management (E/M) service codes distinguish between “new” and “established” patients. A patient is new if he or she has not received a face-to-face, professional service from the provider, or a provider of the same specialty/subspecialty in a group practice, within the previous 36 months. This is commonly known as the “three year rule.”

If another member of the group has seen the patient for a different problem within the past three years, but that provider is of a different specialty/subspecialty, you might still report a new patient service. For instance, a patient consults with an orthopedist for possible hip replacement. The patient saw an internist in the same group practice several times in the past three years. In this case, the patient is new to the orthopedist, but established for the internist.

For a list of Medicare-recognized physician specialties, check the CMS website here.

One common question is how to determine the patient’s status if the provider has seen a patient previously in a different location (such as at another practice, or in a facility). The short answer is, where the patient is seen doesn’t matter. The June 1999 issue of AMA’s CPT Assistant explains:

Consider Dr A, who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A.

By the same logic, if a physician has provided face-to-face services in the hospital, and sees that same patient in his or her office within three years, the patient is established.

Note that only face-to-face services count toward a patient’s new or established status. CPT’s® E/M Services Guidelines stress, “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).” A patient might still be new, for instance, if the physician had interpreted test results a month earlier, but had provided no face-to-face within the previous three years. CMS Transmittal R731CP, Change Request 4032 affirms this, stating, “An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

Make the right choice, quickly: To determine if a patient is new or established, follow the “Decision Tree for New vs. Established Patients” in the CPT® E/M Services Guidelines.


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