New vs. Established Patients: Who’s New to You? (2024)

Billing for new patients requires three key elements and a thorough knowledge of the rules.

A persistent concern when reporting evaluation and management (E/M) services is determining whether a an individual is a new patient to the practice or already established. New patient codes carry higher relative value units (RVUs), and for that reason are consistently under the watchful eye of payers, who are quick to deny unsubstantiated claims. Here are some guidelines that will ensure your E/M coding holds up to claims review.

Be Sure New vs. Established Applies

Not all E/M codes fall under the new vs. established categories. For example, in the emergency department (ED), the patient is always new and the provider is always expected to document the patient’s history in the medical record.

In the office setting, patients see their provider routinely. The provider knows (or can quickly obtain from the medical record) the patient’s history to manage their chronic conditions, as well as make medical decisions on new problems.

A provider seeing a patient for the first time may not have the benefit of knowing the patient’s history. Even if the provider can access the patient’s medical record, they will probably ask more questions.

Who Is a New Patient?

The definition of a “new” patient is given in the CPT® code book:

A new patient is one who has not received any professional services 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.

See Also

Claim rejection for non-disclosure of pre-existing disease (PED) post-waiting period

In addition to this definition, the Centers for Medicare & Medicaid Services (CMS) adds in Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7):

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.

Let’s break down the three key components that make up the new patient definition:

Professional Service: When physician coders see this, we automatically think of modifier 26 Professional services. This leads us to think that if the provider bills a claim for radiology or labs, and sees the patient face to face, an established patient office visit must be billed. This is not true, per the aforementioned CMS guidance. If the provider has never seen the patient face to face, a new patient code should be billed.

Example: A patient presents to the ED with chest pain. The ED physician orders an electrocardiogram (EKG), which is interpreted by the cardiologist on call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. The patient is sent home and asked to follow up with the cardiologist next week for coronary artery disease. At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, but did not see the patient face to face.

Three-year rule: The general rule to determine if a patient is new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.

Example: A patient is seen on Nov. 1, 2014. He moves away, but returns to see the provider on Nov. 2, 2017. Because it has been three years since the date of service, the provider can bill a new patient E/M code.

Different specialty/subspecialty within the same group: This area causes the most confusion. For Medicare patients, you can use the National Provider Identifier (NPI) registry to see what specialty the physician’s taxonomy is registered under. For payers, this usually is determined by the way the provider was credentialed.

Those who are part of the credentialing process must understand how important it is to get the provider enrolled with the payer correctly. Denials will ensue if this is not done correctly.

New to Whom?

Problems begin when doctors switch practices, send patients to mid-levels, and cross-cover for each other. Here are some examples of these situations:

• If a doctor changes practices and takes his patients with him, the provider may want to bill the patient as new based on the new tax ID. This is incorrect. The tax ID does not matter. The provider has already seen these patients and has established a history. He cannot bill a new patient code just because he’s billing in a different group.
• If a doctor of medicine (MD) or doctor of osteopathy sends a patient to a mid-level provider (i.e., nurse practitioner (NP) or physician assistant (PA)) and the visit does not fall under incident-to, the NP or PA could bill a new patient code if they are a different specialty with different taxonomy codes. If the MD is a family practice provider and the NP sees hematology patients, for example, the specialty is different and a new patient code can be billed. But if the NP is also considered family practice, it would not be appropriate to bill a new patient code.
• If one provider is covering for another, the covering provider must bill the same code category that the “regular” provider would have billed, even if they are a different specialty. For example, a patient’s regular physician is on vacation, so she sees the internal medicine provider who is covering for the family practice doctor. The internist must bill an established patient code because that is what the family practice doctor would have billed.

Know the Exceptions

There are some exceptions to the rules. For example, some Medicaid plans require obstetric providers to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to her becoming pregnant. Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.

Know When to Appeal

If a claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal.

See also “Navigate the New vs. Established Patient Decision Tree.”

Resource
Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.7)