Evaluation and management codes
New vs. established patients
New vs. established patient: In a nutshell
- New patient: A person who has not received professional face-to-face (billable) care from you or any other medical provider of the same specialty and in the same practice within the last three years.
- Established patient: A person who has received professional face-to-face (billable) care from you or another medical provider with the same specialty in the same practice within the last three years.
- If an established patient comes to you with a new problem, they are still considered established.
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Either a patient is new or a patient is established. Sounds simple, right? In theory, yes. In practice, not necessarily.
Sometimes, whether someone is a new or established patient isn’t straightforward. A patient who has moved from across the country and has never seen a dermatologist in his life is certainly a new patient. Similarly, a patient who you have seen once a month for the past three years is, by all means, established. Those are easy. But there are some cases where it’s a little trickier.
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If an established patient comes to you with a new problem, they are still considered established. They have received treatment from you within the past three years, so they cannot be documented as a new patient.
Getting the patient’s status correct is an important part of coding, since it affects your reimbursement. If you accidentally code an established patient as a new one, you may be up-coding, which can become a financial nightmare. On the other hand, if you code a new patient as an established one, you may down-code the encounter, and not get the reimbursement you deserve.
Reminder
The actual location where you see your patient doesn’t make a difference in their new vs. established status. A group practice is defined by their National Provider Identifier (NPI) and Tax ID Number (TIN). CMS will look at these numbers, as well as your primary specialty taxonomy code. It will not look at the address of the physical building where you practice.
You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.
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