New or Established Patient? It Depends

Most coders are familiar with the general rule of New vs. Established Patient for professional billing. That rule indicates, “If the patient has been seen by that provider or another provider of the same specialty that bills under the same Tax Identification Number (TIN) within the past three years, the patient is considered to be an Established Patient.” However, that’s just the starting point in determining the correct code set to use.

If a patient has had a non-face-to-face service only, such as a lab service, but has never been seen for an Evaluation & Management, Surgery or other face-to-face service, then the patient is still considered New. It’s also important to remember that the patient follows a provider NPI, not necessarily the TIN. For example, if a practice is acquired by another entity and starts billing under a new TIN, but the patient has been seen by the provider before, the patient is still considered Established. A New patient code should not be billed just because there is now a new billing TIN.

The billing rules for a facility are different, a fact that can be confusing to coders, especially those who focus more on professional coding. If you’re a hospital coder, the important distinction is that any visit to any part of the hospital within the past three years means that patient should be billed with the Established Patient code set. Prior to 2008, the CMS OPPS rule indicated any visit, no matter how long ago, made a patient Established. Then, effective January 1, 2014, Medicare eliminated the payment difference between New and Established codes for facility services, combining all outpatient E&M codes into one G code, with the exception of ED codes.

Is your patient considered New or Established? Take the above information into account, and you’ll be on your way to selecting the correct code family.