Coding refresher: How to determine new vs. established patients

Q: We are implementing a policy to define new and established patients. Can you please refresh our understanding of how to determine this?

A: New patient codes carry higher relative value units and for that reason are consistently under the watchful eye of payers, who are quick to deny unsubstantiated claims.

Who is a new patient?

According to the Current Procedural Terminology codebook, a “new” patient is “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

The Centers for Medicare & Medicaid Services further defines a new patient in Medicare Claims Processing Manual, Chapter 12 (30.6.7) as follows:

“An interpretation of a diagnostic test, reading an x-ray or EKG (electrocardiogram) etc., in the absence of an E/M (evaluation and management) service or other face-to-face service with the patient does not affect the designation of a new patient.”

What do each of these key components mean? Let’s break it down.

Professional service: If the provider has never seen the patient face to face, a new patient code should be billed.

Three-year rule: The general rule in determining whether a patient is “new” is that a previous, face-to-face service must have occurred at least three years prior to the date of the current service.

Different specialty/subspecialty within the same group: This area causes the most confusion. For Medicare patients, you can use the National Provider Identifier registry to see what specialty the physician’s taxonomy is registered under. For other payers, this usually is determined by the way the provider was credentialed.

New to whom?

If a doctor changes practices and takes his patients with him, the provider may want to bill the patient as new based on the new tax ID. This is incorrect. The tax ID does not matter. The provider has already seen these patients and established a history. He cannot bill a new patient code just because he’s billing in a different group.

If a doctor of medicine (M.D.) or doctor of osteopathic medicine sends a patient to a midlevel provider, such as a nurse practitioner (NP) or physician assistant (PA), and the visit does not fall under “incident-to,” then the NP or PA should calculate new vs. established patient based on the specialty in which they are working. If the M.D. is a family practice provider and the NP sees hematology patients, for example, the specialty is different and a new patient code can be billed. But if the NP is also considered family practice, it would not be appropriate to bill a new patient code.

If one provider is covering for another, the covering provider must bill the same code category that the regular provider would have billed, even if they are a different specialty. For example, a patient’s regular physician is on vacation, so she sees the internal medicine provider who is covering for the family practice doctor. The internist must bill an established patient code because that is what the family practice doctor would have billed.