Observe 3-Year Rule When Deciding New vs. Established

Posted on 15 Sep, 2015 |comments_icon 4|By Chris Boucher

Patients who have been to your practice might qualify as ‘new.’

If you haven’t brushed up on the new vs. established patient rules for office E/M services lately, here’s a quick FAQ on when to select each.

Who is a new patient?

Quite obviously, if your practice sees a patient for the first time ever, you should choose a new patient E/M code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: …). There are also times when a patient is considered “new” even if she’s been a patient to your practice before.

According to WPS Medicare, a new patient “has not received any professional services from the physician within the previous three years. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”

Who is an established patient?

For coding purposes, an established patient “has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years,” states WPS Medicare.

Let’s say general physicians A and B both work for the same group practice. Physician A performs an office E/M in July 2013 for a patient’s stomach pain. In May 2015, physician B performs an office E/M for the same patient to address her neck pain.

For the 2015 visit, you should choose an established patient E/M code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …)

Are there exceptions to the new/established rules?

It depends on your practice’s scope and the payer. If your practice includes sub-specialists, and the payer allows it, situations might arise in which new patient E/M codes are appropriate for an otherwise established patient.

Best bet: Look before you leap. Contact your payers and ask how they apply new and established patient guidelines – specifically with regard to different specialties and sub-specialties in the same group practice.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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