According to the American Medical Association’s CPT® book, a new patient is a patient who “has never 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.
There is an excellent chart in the front section of the CPT® book to help differentiate between a new patient and an established patient. If you have a question about whether the patient is new or established look at that chart in the CPT® book, and the answer may well be clear. Specialty designation is critical for this. When you send your enrollment applications to Medicare or other third parties, you select a physician specialty. That specialty designation is used in determining whether a patient is new or established.
According to the CPT® book, a professional service for the purpose of determining the difference between new and established patients is any face-to-face service, including E/M services or procedures. It does not include diagnostic interpretations.
Other key points:
• Be careful when billing for physicians in multiple locations.
• A new chart does not equal a new patient visit.
• In the instance in which a physician sees a patient in one practice, and then joins a new practice, patients from the old practice seen in the new practice are established patient visits when seen within the three-year period.
From the Medicare Claims Processing Manual:
30.6.7 - Payment for Office or Other Outpatient Evaluation and
Management (E/M) Visits (Codes 99201 - 99215)
(Rev. 731, Issued: 10-28-05, Effective: 01-01-04 Chemotherapy and Non-
Chemotherapy drug infusion codes/01-01-05 Therapeutic and Diagnostic injection
codes, Implementation: 01-03-06)
A Definition of New Patient for Selection of E/M Visit Code
Interpret the phrase “new patient” to mean a patient who has not received any
professional services, i.e., E/M service or other face-to-face service (e.g., surgical
procedure) from the physician or physician group practice (same physician specialty)
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., a lab interpretation is billed 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 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.
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