New Versus Established Patients Visits: 2.0

Confusion persists in understanding the definition of the two visits.

We created a lot of buzz the past two weeks on our Talk Ten Tuesday broadcast an article on new versus established patient visits: so much, in fact, it was hard to keep up with all the email feedback, which was very much appreciated.

Because of some of the ongoing confusion on when to code and report, as well as new versus established patient visits, we thought we’d clarify even more with specific examples, and explain how CPT® and Medicare are consistent but slightly different in their approach.

To revisit:

The CPT manual differentiates between new and established patients:

• 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. The CPT code group is 99201-99205.
• 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. The CPT code group is 99211-99215.

However, the Centers for Medicare & Medicaid Services (CMS) has slightly different definitions of new and established patients in the Medicare Claims Processing Manual, Chapter 12, Physician/Nonphysician Practitioners, Section 30.6.7:

• Interpret the phrase “new patient” to mean a patient who has not received any professional services (i.e., evaluation and management, or E&M service) or other face-to-face services (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation) is billed and no E&M service or other face-to-face services with the patient is performed, then this patient remains a new patient for the initial visit. 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 services with the patient does not affect the designation of a new patient.

Professional services: This term can be interchangeable with the term “physician services.” Professional and/or physician services are face-to-face services, which include office visits, surgical procedures, and a broad range of other diagnostic and therapeutic services. These services are furnished in all settings, including physician offices, hospitals, other post-acute care settings, and clinical laboratories. For example, suppose a provider reviews a diagnostic image or lab for an inpatient he or she did not actually meet in person, and the patient is referred to a cardiologist upon discharge. At that next visit, assuming it would be in the office setting, the cardiologist would bill a new patient visit because there was no face-to-face encounter during the inpatient stay.

Three-year rule: The general rule for all payers in determining 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. For example, say a patient is seen in the office by their PCP on Feb. 10, 2016. He moves out of state for a new job, but moves back to the area and makes an appointment with the office to see his PCP on March 1, 2019. Because it has been a full three years since his last date of service, the office will bill this as a new patient visit.

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 under what specialty the physician’s taxonomy (specialty designation) is registered. For many payers, this usually is determined by the way the provider is 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.

Medicare considers hospitalists and internal medicine providers the same specialty, even though they have different taxonomy numbers.

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 patients as new based on the “new” tax ID and the fact that the physicians in his new practice have not seen the patients before. 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. The other physicians in his new practice basically have the “guilt by association” of the established visit as well. Now, if that physician sold his practice to another practice and did not follow those patients, those patients would be new to the new practice.

If a doctor of medicine (MD) or doctor of osteopathy (DO) sends a patient to a mid-level provider (i.e., nurse practitioner, or NP, or physician assistant, or 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 oncology patients, for example, the specialty is different, and a new patient code can be billed. But if the NP is also considered a 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, and even if the covering physician has never seen the patient before (CPT Prof Edition P.4). For example, say 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. 

Multiple practice sites, same tax identification number: Consider the scenario in which a group practice has multiple sites of care, all billing under the same tax identification number, and each site has its own patient records that may not be readily available at other clinic sites. A patient is a regular at clinic site A but was sent to clinic site B to be evaluated by a different physician or non-physician provider (NPP) who has never seen the patient and has no records available. Should this patient be coded as a new patient or an established patient? If a patient has been seen in the previous three years by any physician or NPP in the same group and specialty, regardless of which clinic site they went to and regardless of whether patient records are available, only established patient codes should be used. CMS and CPT rules do not provide exceptions to practice sites that do not have access to records.

Know when to appeal: If a new patient 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 with the ammunition we have provided here.

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