Skip to main content
  • Is the Patient New or Established? Test Your Knowledge

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

    Download PDF

    Payment for a patient exam can vary depending on whether the patient is established or new, in which case you would get paid more.

    Who is considered a new patient? The Current Procedural Terminology (CPT) defines a new patient as “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.”

    What is a professional service? For the purpose of determining whether a patient is new or established, CPT defines professional services as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management [E&M] services reported by a specific CPT code(s).”

    What happens if you see an established patient but bill for a new pa­tient? Many commercial plans would either deny the claim or, perhaps, change the CPT code from new to established. Furthermore, CMS has tasked Recov­ery Audit (RA) entities with identi­fying practices that have incorrectly used E&M or Eye visit codes that are reserved for new patients. The RA en­tities use data mining to identify such practices and will seek to recoup im­proper payments. (For more on audits, including a list of issues that auditors are targeting, see

    New or Established?

    Q1—92228–26. Some health plans use the Healthcare Effectiveness Data and Information Set (HEDIS) to track perfor­mance. To meet a HEDIS requirement, a primary care physician (PCP) asked you to provide her with the interpreta­tion and report of a fundus photo on a patient with known retinopathy. This patient had never been seen by you or anyone else in your group practice. You submit CPT code 92228–26 for the professional component of remote im­aging for monitoring and management of active retinal disease, (e.g., diabetic retinopathy) with physician review; interpretation and report, unilateral or bilateral. That same patient now comes to see you for retinopathy. Would you bill for a new or established patient?

    Answer. Surprisingly, this qualifies as a new patient exam. According to CMS Transmittal 1231, “if a professional component of a previous procedure is billed in a three-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.”

    Q2—loyal patients follow their doctor to her new clinic. A local oph­thalmologist in solo practice has now joined your group practice. Many of the patients she saw at her old clinic follow her to your clinic. Should these be billed as established patients or—since this is their first time in your clinic—new ones?

    Answer. If it has been less than three years since she last examined them, they should be billed as established patients. (Patients are tracked by the physician’s 10-digit National Provider Identifier.)

    Q3—follow-up after inpatient consult. The patient’s PCP requested a hospital inpatient consult with you. Follow-up was scheduled at your office. When the patient comes to the office for the first time, should you bill him as a new or established patient?

    Answer. Because of the earlier face-to-face encounter, he is an established patient. (Tip: It is wise to verify insur­ance participation when the patient fol­lows up with you in the office setting.)

    Q4—change of TIN. A practice is acquired, and a new practice Taxpayer Identification Number (TIN) is created for it. The office location and phone numbers are the same, but the physi­cians who had worked there under the old TIN have all retired. None of the physicians working there under the new TIN were there before the buyout. Are patients from the acquired practice new or established?

    Answer. If the patients have not been examined by any of the current ophthalmologists within the past three years, they would be considered new.

    Congratulations to Specialist Coders

    From January 2018 through June 2019, nearly 600 physicians and staff members have passed the Ophthalmic Coding Specialist (OCS) exam and/or the OCS Retina exam, which helps to assure the coding competency of their practices. Learn more about the exams at

    Q5—preexamination testing. A very busy referral cataract practice has new patients come to the office, and all testing is performed days before their actual exam with the surgeon. That way, the surgeon has all the information when making critical decisions with the patient about their upcoming surgery. Should the visit with the surgeon be billed as an exam for an established patient or—since this was the patient’s first patient face-to-face encounter with the physician—a new patient?

    Answer. While hospitals can have standing orders for tests, payer rules for physician office–based exams require the physician to evaluate the patient and then order any necessary testing. In this scenario, billing for a new patient exam could trigger an audit. The testing services performed prior to physician’s examination of the new patient would be considered standing orders and, as such, are not billable to the payer, only the patient. To conform with insurance billing protocol, the new patient should first be examined, and then tests that are medically necessary can be delegated. (For more on tests, see “How to Make Sure Your Billing for Tests Passes an Audit” YO Info, June 5, 2017.)