Clarifying New Patient vs Established Patient

A new patient is an individual who has not received any face-to-face professional services, Evaluation and Management (E/M) or other service (e.g., surgical procedure), from the same physician or physician group practice (same physician specialty) within the previous three years.

Verify the new patient E/M codes are accurate to submit or if the established patient E/M codes should be submitted.

If Dr. A furnished a service to a patient at a previous clinic, then moved to a new clinic and the patient continued to receive treatment from Dr. A at the new clinic, this is an established patient to Dr. A. The new vs established patient is not determined by a new location.

CMS guidance can be found in the Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.7

Noridian webpage: New Patient vs Established Patient Visit

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