What Makes a New Patient New?
By Emily Hill, PA-C

This article is derived from the McMahon Archives. This information may be time sensitive and was archived on 4/3/2001

Coding a patient as new or established makes a big reimbursement difference.
By Current Procedural Terminology (CPT) definition, a new patient is "one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years." The distinction between new and established patients applies only to the categories of Evaluation and Management (E/M) Services titled "Office or Other Outpatient Services" and "Preventive Medicine Services."

The reason to distinguish a new patient from an established patient is that new patients generally require more work. It is easier to assess the situation of an established patient because you are familiar with the patient’s history and general medical findings. Therefore, under the Resource-Based
Relative Value Scale, new-patient services have a higher reimbursement than established-patient codes at the same level. It also means that when you are selecting a new patient level of service, you must meet or exceed the requirements for all of the "key" components (history, exam, medical

As changes occur in the way healthcare is delivered, what seems like a simple definition can become complex. For example, payers have had varying interpretations of what constitutes a "professional service." The American Medical Association, for example, considers any non-administrative service to be a professional service, even if there is no face-to-face encounter.

In the E/M Services Guidelines in CPT 2001, professional services are defined as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)." This is regardless of where the service was provided. Suppose you provided the interpretation of a test, such
as a magnetic resonance image, to an inpatient you did not actually meet in person. This patient then makes an appointment with you sometime within the next three years. According to the new CPT interpretation, when he (or she) presents to your office, you would report the services you provide using the category of new patient codes. The key words are "face-to-face" and "reported by a specific CPT code(s)." If you are in solo practice, all you need to remember to select the category of service is
whether you provided a face-to-face service within the last three years.

Group Practice Distinctions
The situation is different, however, for group practices. Payers generally recognize all providers who use the same group tax identification number as being part of a single group. In a single-specialty practice, the patient’s encounter should be reported with the new patient category if the patient has not been seen by any provider in that group within the last three years. In a multispecialty practice, the patient is considered new even if he (or she) has received care from several other physicians in the group and a medical record is available. The distinguishing factor here is the specialty designation of the provider. Medicare has a list of specialty and subspecialty designations that it recognizes for payment purposes. Other payers may use this same list or may even recognize more areas of
expertise than Medicare. It is important to accurately denote your specialty and/or subspecialty.

Take, for example, a patient who is seen regularly by the family physicians in your group. She makes an appointment with a psychiatrist in the same group. Her chief complaint is one that has been addressed in previous visits with the family physician. Regardless of having an established medical record and an existing problem, the patient would meet the definition of a new patient for the visit with the psychiatrist, since the physicians are of different specialties.

Other Considerations
It is not uncommon for a physician to change group practices. If an established patient follows Dr. Jones to his or her new group, then the encounter would be classified as an established patient visit in the new location, since Dr. Jones has provided professional services to the patient during the last three years.

When a group provides coverage for another physician group, then the patient encounter is reported with the same category it would have been had it been provided by the initial physician.

Getting It Right
When determining whether to code using new or established patient codes, ask yourself the following:

Have I seen the patient within the last three years? If the answer is yes, then you can stop here. The patient is considered an established patient regardless of whether or not you are now in a group practice. If the answer is no, then ask:

Has the patient been seen by another provider in the same specialty in my group during the past three years? If this answer is also no, then report the services using new patient codes. If the answer is yes, then ask:

Is the physician of a different subspecialty? If the answer is no, report the service using the appropriate level of established patient codes. If the answer is yes, check with your office or billing manager to see if the payer recognizes the subspecialty designation or if there are other circumstances to consider. Remember, some of these encounters might appropriately be billed with consultation codes.