Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
How many of you have had to educate providers on what is considered a new patient vs an established patient so frequently that you sound like a broken record? We auditors, coders and educators know what CPT states about new vs established patients, but we need to understand why it still comes across as confusing to many. We read the CMS manual on what they consider a new patient, then we read the CPT definition, and we can see why it can be confusing. As I always state, you must pay close attention to which payer you are billing for and follow their guidelines.
There is often confusion for organizations when billing a new patient for both the “professional” vs “facility” charges. Suppose you are part of an organization that bills professionally on a 1500 form and facility charges on a UB04 form. What is considered a “new patient,” to both the professional and facility sides, might have different meanings. This article will only address the professional services provided and billed on the 1500 form.
The 2023 Evaluation and Management changes took effect as of January 1, 2023. In the updated guidelines, the AMA have made some revisions and clarifications regarding new vs established and initial vs subsequent. The E/M section is divided into broad categories: office visits, hospital inpatient or observation care visits, and consultations. Most categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and two subcategories of hospital inpatient and observation care visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes.
Note: No distinction is made between a new and an established patient in the emergency department. E/M service in the ED category may be reported for any new or established patient who presents for treatment in the ED.
New patient Professional Services
To distinguish between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.
New Patient (AMA)
Per AMA, a new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
New Patient (CMS)
CMS Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face services (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.
For example, suppose a professional component of a previous procedure is billed in a 3-year time period. In that case, e.g., a lab interpretation is billed, and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. On the other hand, an interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
Established Patient (AMA)
An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
Note:
In the instance where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, per AMA, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. Below we will go through some examples and rationale for deciphering between a new and established patient visit.
Examples
Example 1
A patient visits the office for a follow-up visit with their Internal Medicine provider. The patient last saw the provider six years ago. Per AMA and CPT, a new patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. This visit can be coded utilizing the new patient office or other outpatient services E/M (99202-9905).
Example 2
Ms Scott comes in for her annual Neurology visit. It was communicated that since her last visit six months ago, her neurologist Dr Wilson has left the practice and today, she will be seeing her colleague Dr Clarke. Although this will be the patient’s first-time seeing Dr Clarke because she saw Dr Wilson six months ago, they are a part of the exact same specialty, which would be considered an established patient visit per AMA and CMS. Therefore, this visit can be coded utilizing the established patient office or other outpatient services E/M (99211-99215).
Example 3
Mr Jones sees his primary care provider for pain in his ankle. His primary care provider then evaluates and gives him a referral to Orthopedics. Since Orthopedics has never seen the patient before and is being referred by the primary care provider of a different specialty, this visit is considered a new patient visit and can utilize the new patient office or other outpatient services E/M (99202-99205).
Initial vs Subsequent visit
Initial Service
Some categories apply to both new and established patients (e.g., hospital inpatient or observation care). These categories differentiate services by whether the service is the initial service or a subsequent service. For the purpose of distinguishing between initial or subsequent visits, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services. Initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the inpatient, observation, or nursing facility admission and stays.
Subsequent Service
A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the admission and stays.
Examples:
Example 1
Ms Downs comes to the emergency department for uncontrolled type 2 diabetes Mellitus. The ED provider requests a consultation from Dr Smith from Endocrinology. Dr Smith evaluates the patient and decides the patient needs to be admitted. The next day Dr Smith is off, but his colleague Dr Leaf follows up on the medical-surgical unit to see Ms Downs. What code selection would Dr Leaf bill? Per the AMA guidelines, this 2nd visit with Dr Leaf is considered a subsequent visit using E/M service codes (99231-99233).
A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the admission and stays. For example, although this is the first time Dr Leaf sees Ms Downs, his colleague saw the patient the previous day in the emergency room (same stay or admission). The providers are in the same exact specialty, and Dr Leaf is covering for Dr Smith.
E/M Service providers
Per CMS MLN, To receive payment from Medicare for E/M services, the Medicare benefit for the relevant type of provider must permit them to bill for E/M services. In addition, the services must also be within the scope of practice for the relevant type of provider in the state where they are furnished.
Selecting the code that Best selects the service Furnished
Billing Medicare for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents:
● Patient type
● Setting of service
● Level of E/M service performed
In summary, reviewing guidelines and continued education and training for coders, auditors, providers, billing staff and IT plays an integral part in the documentation, coding and billing of E/M services. The revisions are new and effective as of January 1, 2023, and we must continually educate all and stay abreast of changes. For any documentation discrepancies a coder may identify in the record, it is always best to query the provider for clarification. Since guidelines and payer policies are constantly changing, refresh yourself on what is considered a new patient vs an established patient on the professional side, as well as initial vs subsequent patient visit.
If you would like to schedule training for your organization or private practice providers or schedule a chart review email us today at info@kwadvancedconsulting.com, schedule a call or visit the website and fill out the “contact us” form.
Resources:
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
