Why is a patient considered new after 3 years

New Patient

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management (E&M) services using a specific CPT code(s). 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.

Established Patient

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.

Clear and concise medical record documentation is critical to providing patients with quality care. When billing for a patient’s visit, select the level of E&M service 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 or 1997 Documentation Guidelines for E&M Services.

The rationale for new versus established patients, per CMS, is also based on the provider’s National Provider Identifier (NPI).

Now, when looking at specific examples, it gets a bit trickier when making sure you as a provider are not losing revenue, when there is an opportunity to bill for a new patient visit over an established. However, we also want to be clear when the patient falls into the established patient category and not over-code.

1. Examples:
   1. New Patient

      A newborn comes to your practice for her first encounter after leaving the birth hospital, where your group does not have hospital privileges. No physician or qualified healthcare professional had any face-to-face services with this infant in the hospital.

      A 7-year old patient returns to your practice. The last face-to-face professional service was a little over three years ago. A little over two and half years ago, you called in a refill for this patient’s allergy medication. (Teaching point: Calling in a prescription does not define a professional service, because there was no face-to-face component.)

      You are in a multi-specialty clinic. The patient was seen by a general orthopedic surgeon, but you are board-certified in the hand surgery orthopedic subspecialty and are credentialed with the payors for that. No one in your subspecialty has ever seen this patient, and you are asked to evaluate the patient for wrist pain and possible nerve impingement. (Teaching Point: Because a hand surgeon is considered a “sub-specialty” of orthopedic and has a separate taxonomy code (designation) with Medicare, this qualifies as a new patient visit.)

      You are a cardiologist and are asked to read and review an EKG for a patient. You read it (and bill for the reading/interpretation) and call the PCP to have the patient follow up with you for care. The patient presents to your office for the first time (not a consultation). (Teaching point: Reading and billing for an EKG does not count as a professional service, as there is no face-to-face contact with the patient.).

      Consider the patient who is new to the community and needs a refill of her oral contraceptives. You agree to call in a prescription that will meet her needs until she can be seen in your office the following week. When you see her for her well-woman visit, you report a new patient preventive medicine service code. (Teaching point: since you did not have a face-to-face encounter with the patient when calling in her prescription, this was a new patient.)

   2. Established Patient

      A newborn comes to your practice for the first encounter with a pediatrician after discharge from the birth hospital. One of your pediatricians rounded on the baby in the hospital. (Teaching point: Location of service will not matter; a professional service occurred within three years, so they are an established patient.)

      You are covering for a general surgeon who is out of town for a few days. You have a coverage arrangement with the surgeon. An established patient of his comes to see you. (Teaching point: When you are “covering” for another physician and his patient sees you, you code based on their establishment with the unavailable physician – if the patient is established to them, the patient is established to you.)

      A GI physician leaves one group practice and joins another gastroenterology group. Some of her patients follow her to the new practice. One of the patients who followed was established to the gastroenterologist, presents to the new practice, and sees one of the other GI physicians in the practice. (Teaching point: Because the patient is considered established to the new gastroenterologist, that patient is considered established to all physicians in that new practice who are of the same specialty and subspecialty. A change in address, tax ID, or physical location will not matter.)

      A patient presents to the pediatrician in the office. Her only visit previous was performed by the nurse practitioner. (Teaching point: A patient is established if she has seen a nurse practitioner because the nurse practitioner takes on the same specialty as the physician practice, per CPT). 

The distinction between new and established patients applies only to the categories of E&M services titled “Office or Other Outpatient Services” and “Preventive Medicine Services.” The reason for learning to distinguish new patients from established patients, apart from following coding guidelines, is that it enables you to be reimbursed for the additional work that new patient visits warrant. Another important difference between the codes is that the new patient codes (99201–99205) require that all three key components (history, exam, and medical decision-making) be satisfied, while the established patient codes (99212–99215) require that only two of the three key components be satisfied. So we can argue, in some cases, not distinguishing new patients from established patients can amount to shortchanging yourself. For example, a visit that produces a comprehensive history, comprehensive exam, and decision-making of high complexity qualifies as a level-V visit (99215) if the patient is established and a level-V visit (99205) if the patient is new. The established patient visit amounts to 4.39 NF RVUs ($144.94), while the new patient visit amounts to 6.23 NF RVUs ($205.64). If this was coded incorrectly, the loss to the physician would be $60.70.

Think about that as you think about this question once again: is this patient new or established?

Program Note:
Listen to Terry Fletcher report this story live today on Talk Ten Tuesday, 10-10:30 a.m. EST.

There are other articles on CodingIntel about the difference between new and established patients, and the rules haven’t changed, but that doesn’t mean it is always clear. I hope this blog post clarifies the issue.

Medicare definition

“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.”

CPT® definition

“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).  A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

From CPT®: “When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and same subspecialties as the physician. “

Specialty designation

When physicians enroll in Medicare and private insurance companies, they self-designate their specialty This is typically the same as their board certification. CMS has a list of two-digit specialty designations that they use at enrollment and to process claims.  Although there are more specific taxonomy specialty codes, CMS uses the two-digit code to process claims.  A surgeon who specializes in breast surgery is enrolled in Medicare as a general surgeon. There isn’t a two-digit code for breast surgery, bariatric surgery, or wound care surgeon, for example. If all of these surgeons are in a single surgical group, they are considered the same specialty.

Enrollment and credentialing for non-physician practitioners (NPPs), and claims processing, is done differently by Medicare and commercial carriers.  Medicare enrolls all nurse practitioners, working in any specialty, as nurse practitioners.  Medicare enrolls all physician assistants, working in any specialty, as physician assistants.  They are not enrolled based on the specialty in which they are working.

Most commercial payers enroll NPPs based on the specialty in which they work, and make a distinction between NPPs working in primary care and those working in specialty practices.  This allows the payer to assign different co-pays for visits done by NPPs working in primary care and specialty practices.

The CPT® rule is to consider NPs and PAs as working in the exact same specialty as the practice in which they are assigned. “When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.” This is in the E/M section of the CPT book.

Group membership

Although neither CPT® nor CMS define group membership in their definitions, physicians who report claims with the same tax ID are considered to be in a group.

If a physician changes groups, and patients follow the physician to the new group, they are established patients when seen in the new group. Even though the group tax ID changes. This is because the CPT definition is “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.”  The claim is submitted under the NPI number of the physician–that NPI number is the same, from group to group–so this is an established patient visit.

New versus established

A patient who is sent from Internal Medicine to Orthopedics is considered a new patient, if the patient has not been seen in the past three years. This is true if the clinician who saw the patient in the IM practice was a physician, NP or PA.  There is a decision tree in the CPT® book that can be helpful in determining if a patient is new or established.

• Claims processing, specialty and group membership

Initial visits to different specialty physicians are processed as new patients, if the patient has not seen a physician in that specialty, in that group, in the past three years.

• Claims processing for NPPs

Commercial insurers usually follow the CPT® rule and consider the NPP as being of the exact same specialty as the physician (s) with whom they practice. As mentioned, insurance policies sometimes have a different deductible and different benefit categories for primary care and specialty services.  The company considers the PA who works in an orthopedic office as a specialty provider and the PA who works in a Pediatric practice as a primary care provider. This allows them to process claims depending on if the visit is done in a primary care or specialty practice.

However, since Medicare considers all PAs of the same specialty, and all NPs of the same specialty, they process claims differently.  In a multi-specialty group, if a patient sees an NP in oncology, that patient will be considered established if seen by any other NP working in any specialty.  This can be challenging in a multi-specialty group if new patients are seen by NPs and PAs.

Not all specialties are represented

Then, there are the problems caused by subspecialties not recognized by Medicare.  This is a common problem in general surgery.  There are surgeons who specialize in breast conditions or trauma, and these two subspecialties don’t have a CMS specialty designation. Since there isn’t a CMS recognized subspecialty, then all three of those types of surgeons in the same group will be considered as general surgeons.

Or an internist may provide primary care services and specialize in infectious diseases, as well, even without a board certification.  But, for the purposes of claims processing, only one specialty designation can be selected and is used in claims processing. The internist who has an interest in infectious disease and treats those patients who is signed up as an internal medicine physician will have claims processed as an internist.

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