How to decide whether your patient is new or established

A continuing source of confusion for physicians I consult with is whether the patient should be considered “new” or “established.” While the codes for some services don’t distinguish between new and established patients, the codes for office and other outpatient visits (CPT codes 99201-99215) and preventive medicine services (99381-99397) certainly do.

If coding rules followed common sense, this would be easy. You would just have to ask: Have I seen the patient before? Unfortunately, that straightforward approach does not work. According to CPT, a new patient is a patient who has not been seen by that physician or another physician or other qualified health care professional of the same specialty in the same group practice in the past three years.

Here are reminders regarding three areas of particular confusion:

• "Seen" means for a face-to-face service.
• Where the patient was seen doesn't matter. If a physician cares for a patient in the hospital and then provides follow-up service in the office, the patient is established to the physician, even if it is the first time the patient presents to the office. If a physician changes practices and the patient follows him or her to the new practice, that patient is also considered established, assuming the physician saw the patient in the past three years.
• For the purpose of determining whether a patient is new or established, CPT considers physician assistants or nurse practitioners to be the same specialty as the physician they work with. So a patient you see for the first time would be established if he or she has previously seen a physician assistant or nurse practitioner in your group.

Whether a patient is new or established is not always obvious. But hopefully these reminders will make the task a little less confusing.

— Betsy Nicoletti, a Massachusetts-based coding and billing consultant