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Coding Corner: How coding guidelines define new vs. established patients



July 01, 2016
Area(s) of Interest: Emergency Medicine Payor Issues and Reimbursement 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, the managing editor for AAPC, a training and credentialing association for the business side of health care.   


The distinction between “new” and “established” patients is vital for correct evaluation and management (E/M) code assignment, coding compliance and reimbursement. 


CPT® defines an established patient as one who “has received a professional service from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”


The first requirement of the definition is that a patient has received a “professional service.” Within the context of E/M code selection, CPT® defines a professional service as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s).”


The “face-to-face” nature of a professional service is important: Medicare policy [Centers for Medicare & Medicaid Services (CMS) Transmittal R731CP, Change Request 4032] notes, “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.” A patient is new, for instance, if the physician interpreted test results two years earlier, but had provided no face-to-face service to the patient within the previous three years.


The second requirement of the definition addresses patient status relative to other providers in a group practice. When a patient becomes established with a physician who works in group practice, the patient is established with all physicians of the same specialty/subspecialty in the group. The American Medical Association allows an exception for new physicians seeing for the first time a patient established to the practice. CPT Assistant, November 2008, features the following Q&A:


Question: Can new physicians who come on board to a group practice with their own tax identification numbers charge a new evaluation and management code for patients they see?


Answer: According to CPT guidelines, a new patient is one who has received no professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Also, if a physician is new to this group practice and had never seen or billed a patient previously though his tax ID number, this should be considered a new patient for the purposes of this physician billing for his evaluation and management service.


Not all payors agree with this logic; inquire with your individual payors before billing as new any patient who is established with another physician of the same specialty/subspecialty within a group.


Two providers in the same practice may both classify a patient as new, if they see the patient for different reasons and if the providers are of different specialties recognized by (CMS). For a list of Medicare-recognized physician specialties, visit the CMS website. CPT® guidelines specify, “When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.”


For example, a general surgeon in a large multiple-specialty practice sees a patient in 2014 to remove some skin lesions. In early 2016, the same patient sees an internist—who is a member of the same multispecialty practice as the surgeon who previously treated the patient previously—for a new condition. Because the surgeon and internist (who are of different specialties) saw the patient for unrelated problems, the internist may report the initial visit using new patient codes (e.g., 99201-99205).


If a provider is covering for another provider, a patient’s status is relative to the provider who is unavailable (not the covering provider). For example, Dr. Smith is covering for Dr. Jones, who is on a family vacation. Patients who are established with Dr. Jones would be treated as established with Dr. Smith, even if Dr. Smith has not seen the patient previously.


Finally, note that location doesn’t affect a patient’s “new” or “established” status. CPT Assistant (June 1999) 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.


In other words, where the patient is seen doesn’t matter. If the provider treats a patient with face-to-face service within the previous three years (in any location), that patient is established (in all locations). 

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