New versus Established Patients: Do you Know the Rules and Exceptions?

Not knowing the difference could amount to shortchanging yourself.

It seems like the simpler the question, the harder it can be to answer. When we ask the question, “is this a new or established patient?” it amazes me that it is not a black-and-white answer.
But when we look at the American Medical Association (AMA) Current Procedural Terminology (CPT®) definition and the Centers for Medicare & Medicaid Services (CMS) definition, we have to continue to ask.
First, let’s examine the textbook definition: Definitions:

New Patient

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management (E&M) services using a specific CPT code(s). A new patient is one who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

Established Patient

An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty, who belongs to the same group practice, within the past three years.

Clear and concise medical record documentation is critical to providing patients with quality care. When billing for a patient’s visit, select the level of E&M service that best represents the service(s) provided during the visit. Services must meet specific medical necessity requirements and the level of E&M performed, based on the CMS 1995 or 1997 Documentation Guidelines for E&M Services.

The rationale for new versus established patients, per CMS, is also based on the provider’s National Provider Identifier (NPI).

Now, when looking at specific examples, it gets a bit trickier when making sure you as a provider are not losing revenue, when there is an opportunity to bill for a new patient visit over an established. However, we also want to be clear when the patient falls into the established patient category and not over-code.

1. Examples:
   1. New Patient

      A newborn comes to your practice for her first encounter after leaving the birth hospital, where your group does not have hospital privileges. No physician or qualified healthcare professional had any face-to-face services with this infant in the hospital.

      A 7-year old patient returns to your practice. The last face-to-face professional service was a little over three years ago. A little over two and half years ago, you called in a refill for this patient’s allergy medication. (Teaching point: Calling in a prescription does not define a professional service, because there was no face-to-face component.)

      You are in a multi-specialty clinic. The patient was seen by a general orthopedic surgeon, but you are board-certified in the hand surgery orthopedic subspecialty and are credentialed with the payors for that. No one in your subspecialty has ever seen this patient, and you are asked to evaluate the patient for wrist pain and possible nerve impingement. (Teaching Point: Because a hand surgeon is considered a “sub-specialty” of orthopedic and has a separate taxonomy code (designation) with Medicare, this qualifies as a new patient visit.)

      You are a cardiologist and are asked to read and review an EKG for a patient. You read it (and bill for the reading/interpretation) and call the PCP to have the patient follow up with you for care. The patient presents to your office for the first time (not a consultation). (Teaching point: Reading and billing for an EKG does not count as a professional service, as there is no face-to-face contact with the patient.).

      Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code. (Teaching point: since you did not have a face-to-face encounter with the patient when calling in her prescription, this was a new patient.)

   2. Established Patient

      A newborn comes to your practice for the first encounter with a pediatrician after discharge from the birth hospital. One of your pediatricians rounded on the baby in the hospital. (Teaching point: Location of service will not matter; a professional service occurred within three years, so they are an established patient.)

      You are covering for a general surgeon who is out of town for a few days. You have a coverage arrangement with the surgeon. An established patient of his comes to see you. (Teaching point: When you are “covering” for another physician and his patient sees you, you code based on their establishment with the unavailable physician – if the patient is established to them, the patient is established to you.)

      A GI physician leaves one group practice and joins another gastroenterology group. Some of her patients follow her to the new practice. One of the patients who followed was established to the gastroenterologist, presents to the new practice, and sees one of the other GI physicians in the practice. (Teaching point: Because the patient is considered established to the new gastroenterologist, that patient is considered established to all physicians in that new practice who are of the same specialty and subspecialty. A change in address, tax ID, or physical location will not matter.)

      A patient presents to the pediatrician in the office. Her only visit previous was performed by the nurse practitioner. (Teaching point: A patient is established if she has seen a nurse practitioner because the nurse practitioner takes on the same specialty as the physician practice, per CPT). 

The distinction between new and established patients applies only to the categories of E&M services titled “Office or Other Outpatient Services” and “Preventive Medicine Services.”
The reason for learning to distinguish new patients from established patients, apart from following coding guidelines, is that it enables you to be reimbursed for the additional work that new patient visits warrant. Another important difference between the codes is that the new patient codes (99201–99205) require that all three key components (history, exam, and medical decision-making) be satisfied, while the established patient codes (99212–99215) require that only two of the three key components be satisfied.
So we can argue, in some cases, not distinguishing new patients from established patients can amount to shortchanging yourself. For example, a visit that produces a comprehensive history, comprehensive exam, and decision-making of high complexity qualifies as a level-V visit (99215) if the patient is established and a level-V visit (99205) if the patient is new. The established patient visit amounts to 4.39 NF RVUs ($144.94), while the new patient visit amounts to 6.23 NF RVUs ($205.64). If this was coded incorrectly, the loss to the physician would be $60.70.
Think about that as you think about this question once again: is this patient new or established?

Program Note:
Listen to Terry Fletcher report this story live today on Talk Ten Tuesday, 10-10:30 a.m. EST.