Whether you are starting your own practice, joining a group practice, acquiring patients from another practice or opening a new office location across town, a practice transition will create situations in which it will be important to know if a patient is considered new or established.

Why? Because new patient visits generally require more physician time and paperwork, therefore are usually reimbursed at a higher rate for both the Eye Visit and the Evaluation and Management (E/M) codes. 

A new patient is defined by the Current Procedural Terminology (CPT) 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.”

A good rule of thumb for patients who have not been seen in your clinic for a few years is to look at the last date they were seen and calculate if it is more than three years plus one day. If it has been longer than that, consider them new patients.

CPT defines a professional service as “those face-to-face services rendered by physicians and other qualified health care professionals who may report (E/M) services reported by a specific CPT code(s).” 

Incorrect reimbursement in the form of either overpayment or underpayment will occur when visits are not appropriately billed as new or established. You might get paid, but the payment could be wrong. In an audit situation, the payer would look to recoup these improper payments. Here is a quick five-scenario pop quiz that will help you to apply the new patient rules. 

Scenario 1: Patient Visits New Practice and Old Practice

A retina physician starts a new practice, and a few patients choose to see other subspecialists at the old group practice as well as the retina physician at the new solo practice. How should these patient visits be billed? 

If the last visit at each location was less than three years ago, these patients would be considered established at both practices, and the visits should be billed as such.

Scenario 2: Exam After Testing Service

A patient had a test (SCODI, visual field, biometry, etc.) performed by the technicians of a large group practice that owned the equipment. An outside ordering physician provided the interpretation of the testing service. Two years later, the patient is scheduled to see one of the physicians who was part of the group practice when the patient had the test performed but has since joined another group practice. Is this patient considered new or established? 

The answer is new. Why? Recall the CPT definition for a new patient includes the term “professional service” which is defined as a “face-to-face service rendered by physician and other qualified health professionals.” This patient did not have a face-to-face service with any physician of the large group practice, only the testing service or technical component of the test was performed two years prior. The visit should be billed as new.

Scenario 3: Small to Large Group Practice

A small group of subspecialists merge into one practice and a new Taxpayer Identification Number (TIN) for the large group practice is created. Are patients who have seen physicians at any of the smaller group practices within three years considered new or established? 

The answer is they are considered established. If the patients have not been seen by any physician in the new group practice within three years, they would be considered new. Patients are tracked by the physician’s 10-digit National Provider Identifier.

Scenario 4: On-Call Patient Exams

Two practices help cover each other’s patients on call. A patient from practice A is seen by Practice B’s on-call physician. Practice B’s physician has never seen the patient before. Can this be billed as a new patient examination? 

Answer: Yes, but what is the reason for the exam? If the patient is in a global period of surgery and the problem is related to the surgery, it is not appropriate to bill an exam. It’s considered post-op. When you are on call for another surgeon, it is as if you are the operating surgeon. If the complaint is unrelated to surgery, the exam is billable.

Scenario 5: Exam After Inpatient Consultation

A patient is seen by a physician of a practice for an inpatient consultation at the hospital. After being released from the hospital a few weeks later, the patient is seen by another physician in the same practice. Is this patient considered new or established? 

This patient is considered an established patient of the practice due to the face-to-face encounter with the other physician in the practice.