New or Established Patient? Depends on Payer

When billing insurance for evaluation and management (E&M) services, you have to document if the patient is new or established, depending on whether you’ve had previous encounters with the patient — and depending on which type of plan is paying the bill. 

Current Procedural Terminology (CPT) defines a new patient as one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice, within the past three years. CPT recognizes specialties and subspecialties listed in the National Uniform Claim Committee’s (NUCC’s) Health Care Provider Taxonomy Code Set.

The Centers for Medicare & Medicaid Services (CMS) definition is a little different. It defines a new patient as one who has not received any professional services from the physician/nonphysician practitioner or another physician of the same specialty who belongs to the same group practice within the previous three years.

CMS determines the same specialty by the physician’s primary specialty enrollment in Medicare. The Medicare Claims Processing Manual, Chapter 26, lists Medicare specialties.

CMS also provides a Medicare-specialty-code-to-health-care-provider-taxonomy-code crosswalk. For example, the crosswalk shows that Medicare specialty code 34, Urology, encompasses all three subspecialties listed in the NUCC taxonomy code set: urology, pediatric urology, and female pelvic medicine and reconstructive surgery. So, if a pelvic medicine specialist provided an E&M service to a patient who had seen a urologist in the same practice within the past three years, the pelvic medicine specialist could bill a commercial plan that follows the CPT definition under a “new patient” E&M code. Under the Medicare definition, this patient would be billed as an “established” patient.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. Need extra help with coding and documentation? TMA Practice Consulting can perform custom training, check-ups, and reviews. Call a consultant for more information at (800) 523-8776 or email practice.consulting[at]texmed[dot]org. Also, visit TMA’s Billing and Coding page for additional resources.

Published July 12, 2016

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Last Updated On

July 13, 2016

Originally Published On

July 12, 2016