Examples of New Vs. Established Patients in E/M Services

For fun, let’s take a short quiz. Would you say that the following scenarios would be coded as a new or established patient?

1. A cardiologist interprets an EKG for a patient he has not seen previously. His nurse schedules an appointment for the next day.
2. A pediatric provider orders labs to be completed prior to the first visit.
3. An orthopedic doctor reads and x ray prior to the patient’s appointment.

The answers? Well, all of these would be billed as new patients (as long as the other components are met) because the provider has never seen the patient face-to-face. Don’t get confused on professional component vs. professional service when it comes to new patient codes.

CPT® defines a new patient as someone, “who has not received any professional services from the physician/qualified health care 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.”

But, what is a professional service? How do we determine exact same specialty and subspecialty, and same group practice? And then, of course, we need to talk about the 3 year rule.

Billing for new vs. established patient evaluation and management services can be super confusing because we need to consider the CPT and Medicare guidelines all while knowing the caveats within each.

Tune into my free 60-minute webinar, Finding E/M Clarity: The Subtle Differences Between New vs. Established Patients, to better understand coding distinctions and to properly determine which category to use.

We'll discuss the four main components of new vs. established and how to understand professional service, distinguish between same specialty/subspecialty, breakdown same group, and make sense of the 3 year rule.