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July 19, 2016

New vs Established Patients

CGS is seeing an increase in the number of questions regarding the difference between a "new" patient vs an "established" patient, to clarify:

The American Medical Association (AMA) states:

  • New Patient
    • 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.
  • Established Patient
    • An established patient is one who HAS received professional services from the physician/qualified helath care professional or another physician/qualitied health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

CMS Publication 100-04, Chapter 12, Section 30.6.7 of the Medicare Claims Processing Manual

  • The rules with respect to new and established patient office visits are unchanged.
    • 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 service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
      • For example, if a professional component of a previous procedure is billed in a 3 year time period, 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.
    • 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.

Resources:


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