New vs Established Patient Visit

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

New vs Established Patient Visit
In the past, your billing coder may have had some confusion over the definition of a new versus established patient visit. Some of this confusion stemmed from the fact that Medicare and the CPT Evaluation and Management Services Guidelines had different standards. Medicare stated that if a face-to-face service with the physician occurred in the last three years, this is not a new patient visit. The CPT rules stated that no professional service, for example, interpreting a diagnostic test, could have occurred in order to deem this a new visit.

The dichotomy has changed. There is now agreement that it is only face-to-face contact that determines the status of the visit. Therefore, your nurse could give the patient a flu shot and then the patient could see the physician one week later and this physician contact would be a new visit. One other defining condition is that if you are in a group practice, no other physician of the same specialty should have seen the patient within three years.

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