Skip over navigation

New Patient vs Established Patient Visits

On this page, view the below information.

New Patient - Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service 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 electrocardiogram (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.

If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation.

Established patient – Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.

Clear and concise medical record documentation is critical to providing the patients with quality care. When billing for a patient's visit, select the level of E/M 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 This link will take you to an external website. or 1997 This link will take you to an external website. Documentation Guidelines for E/M Services.

The rationale for new versus established patient is based on the provider's National Provider Identifier (NPI).

Claim Examples

Example 1

A patient has an EKG. It is sent to Dr. Smith, a cardiologist, to read and interpret.

Date of Service Service Provided CPT Code
05/10/17 EKG 93010

Due to cardiac involvement, he/she is referred to Dr. Smith. The patient has never been seen by Dr. Smith or any other cardiologist within this same group practice.

Date of Service Service Provided CPT Code
05/20/17 New E/M 99201

In this situation, a new patient E/M is appropriate as there was no face-to-face visit on 05/10/17.

Example 2

A patient sees Dr. Smith, a cardiologist, for follow up care at "Clinic A."

Date of Service Service Provided CPT Code
06/23/17 Established E/M 99213

Dr. Smith leaves "Clinic A" and joins "Clinic B." The patient follows Dr. Smith to "Clinic B."

Date of Service Service Provided CPT Code
7/15/17 Established E/M 99213

Although Dr. Smith is at a different clinic, the patient is still an established patient with him. Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years.

Example 3

An established patient sees Dr. Smith, a cardiologist, at "Clinic A."

Date of Service Service Provided CPT Code
3/23/17 Established E/M 99213

The patient returns for a follow up visit at "Clinic A" and sees Dr. Jones, a cardiologist.

Date of Service Service Provided CPT Code
4/1/17 Established E/M 99213

Although, Dr. Smith is no longer at "Clinic A," the patient is still considered an established patient for Dr. Jones as Dr. Smith and Dr. Jones are of the same specialty.

Example 4

Dr. Smith, a cardiologist, sees a patient at "Clinic B." The same patient is later seen by Dr. John, a cardiologist, at "Clinic B."

Date of Service Service Provided CPT Code
5/20/17 Established E/M 99213

Dr. Smith and Dr. John are of the same specialty; therefore, the patient is considered an established patient for Dr. John.

Example 5

Kathy Crane, a nurse practitioner (NP) at "Clinic A" sees a patient in the Orthopedic department.

Date of Service Service Provided CPT Code
4/14/17 Initial E/M 99202

Jessica Poole, NP at "Clinic A" sees the same patient in Internal Medicine.

Date of Service Service Provided CPT Code
5/2/17 E/M, new complaint 99213

The patient is still an established patient as both NPPs are of the same NP specialty 50. This specialty does not make a difference if they work in different departments of the same clinic as they are of the same specialty at that group practice.

Resources

 

Last Updated Sep 06, 2017