Medical Billing for New Vs Established Patients

by | Published on Apr 21, 2023 | Medical Billing

Medical Billing for New Vs Established Patients
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Evaluation and Management (E/M) services consist of categories such as office visits, hospital inpatient or observation care visits, and consultations. Evaluation and management (E/M) coding is the use of CPT codes from the range 99202-99499 to represent services provided by a physician or other qualified healthcare professional. As every medical billing company knows, selecting the correct code for many E/M services (office visits, hospital visits, home services, and preventive medicine services) starts with determining whether a patient is new or established.

In medical billing, new patient codes carry higher relative value units (RVUs) compared to established patient codes. This is because the healthcare provider generally has to spend more time and resources to evaluate and establish a treatment plan for new patients. The RVUs assigned to a medical service are based on factors such as the time required to perform the service, the complexity of the service, and the skill level required of the healthcare provider. New patient visits are assigned higher RVUs as they typically involve more time and complexity than established patient visits.

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New Patient vs. Established Patient

Professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report E/M services. Any specifically identifiable procedure or service (i.e., identified with a specific CPT code) performed on the date of E/M services may be reported separately.

New Patient

The CPT codebook defines a new patient as follows:

“A new patient is one who has not received any professional services from the physician or other qualified healthcare professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years”.

CMS further clarifies: “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”.

This means that if a professional component of a previous procedure (e.g., lab interpretation) is billed in a 3-year time period, and no E/M service or other face-to-face service with the patient takes place, this patient remains a new patient for the initial visit.

To bill the correct E/M codes, it’s crucial to correctly determine whether an individual is a new patient to the practice or an already established patient. This depends on understanding the three key elements that make up the “new patient” definition:

  • Professional Service: A new patient code should be billed if:
    • The provider has never seen the patient face to face. For example, a patient has an electrocardiogram (EKG) and it is sent to a cardiologist for interpretation. If the patient is seen by the cardiologist next week for coronary artery disease, a new patient E/M is appropriate as there was no face-to-face visit on the date the EKG was taken.
    • The patient has not received any professional service from any provider of the same practice/group within the past three years
  • Three-year rule: The general rule to determine if a patient is “new” is that a previous, face-to-face service must have occurred at least three years from the date of service.

Example: If an E/M service was provided to a patient on December 6, 2020, and the patient returns to see the clinician on March 6, 2023, a new patient E/M code can be billed as three years have passed since the previous E/M service.

  • Different specialty/subspecialty within the same group: For Medicare patients, the coder can use the National Provider Identifier (NPI) registry to see under what specialty the physician’s taxonomy is registered. For other payers, this usually depends on the way the provider was credentialed.

Established Patient

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

  • If the patient has been seen before within the same practice, even if they are seen by another physician, they are an established patient.
  • If a physician switches practices and takes his patients with him, he cannot bill a new patient code even if the tax ID has changed. These are established patients as the physician has already seen them.
  • If a family physician sends a patient to a mid-level provider, such as a nurse practitioner (NP) or physician assistant (PA), and the visit does not fall under incident-to, the NP or PA can bill a new patient code if they are a different specialty with different taxonomy codes. On the other hand, if the NP is also under family practice, a new patient code cannot be billed.
  • A provider who is covering for another must bill the same code category that the “regular” provider would have billed.

Exceptions to the Rules

  • Emergency Department (ED) Evaluation and Management (E/M) codes are typically reported per day and do not differentiate between new or established patients.
  • Certain Medicaid plans mandate obstetric providers to use a new patient code when billing for the first prenatal visit, irrespective of the fact that they have been treating the patient for several years before her pregnancy.
  • Though hospitalists and internal medicine providers have different taxonomy numbers, Medicare considers them the same specialty.

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There are many code categories in the Evaluation and Management section (99202-99499). Each category may have specific guidelines or the codes may include specific details. Outsourced physician billing services can help practices maximize payment and reduce risk of payer scrutiny by understanding how to properly document and code for E/M services.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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