Is This a New Patient or an Established Patient?

When is a patient who has been to your practice before a "new" patient? When is a patient you are seeing for the first time an "established" patient?

When you are coding the evaluation and management services you provide a patient, this distinction is an important one, as it enables you to receive reimbursement for the additional work new patient visits require.

Yes or No

Ask yourself: Has this patient received professional services from you or another physician of the same specialty who belongs to the same group practice, within the past three years?

  • If the answer is no, this is a new patient.
  • If the answer is yes, this is an established patient.

In this context, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code. Here are some example scenarios:

  • You see a patient for the first time who last saw another physician in your single-specialty group practice more than three years ago. This is a new patient.
  • You see a patient for the first time who last saw another physician of a different specialty in your multispecialty group practice less than three years ago. This is a new patient.
  • You call in a prescription for a patient who is new to the community and needs a refill of his or her regular medication. The following week you see the patient in your office for the first time. This is new patient.
  • You leave one group practice and join another, or you close your solo practice to join a group, and one of your regular patients follows you to the new practice. This is an established patient.
  • You treat a patient in the emergency department who subsequently goes to you for a follow-up office visit. This is an established patient.

Still confused about coding? TMA Practice Consulting can perform a Coding and Documentation Assessment to determine if you are coding your services properly. TMA's certified coding consultants can identify trends, make recommendations for improvement, and provide on-site training for correct coding and documentation procedures. Contact TMA Practice Consulting today at (800) 523-8776 or  for more information. 

Content reviewed: 11/06/07

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