From an outsider’s perspective, it might seem easy to determine who’s who between a new patient and an established patient. A new patient is one who a healthcare practitioner hasn’t treated before, and an established patient is one who they have. However, for a medical biller or coder, it’s not that simple, and any mistake in billing can lead to serious consequences. Hence, here’s what you need to know.

Difference Between New Patient and Established PatientE/M Codes

According to coding guidelines, there are several things that differentiate a new patient from an established patient. CPT (Current Procedural Terminology) defines a new patient as a person who “has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.”

Similarly, an established patient would be a person who has received those services from a healthcare practitioner within that three-year period. Now, there are three key things to consider here, which primarily cause the difference between a new patient and an established patient, and they are:

  • The three-year time period
  • Professional services
  • Group practice

Let’s take a look at each of them.

The Three-Year Time Period

This is pretty straightforward. Basically, a patient can be considered a new patient if their last face-to-face meeting with the physician occurred more than three years ago from the date of the service.

Professional Services

This is where it starts getting a little complicated. Many healthcare practitioners tend to get confused here as to what is included in professional services and therefore, would characterize a patient as new or established.

This is one of the reasons why practices need to hire a competent medical billing company as their knowledge can clarify such confusions and let physicians focus on treating their patients primarily. Considering how CPT defines professional services, the key thing you need to consider is the face-to-face aspect.

If the physician provided some service to a patient, an interpretation, or prescribing a prescription, but didn’t actually meet them face-to-face, it wouldn’t necessarily be counted under professional services. Therefore, when the patient finally meets the physician in person for their treatment, the physician can then report them as a new patient when filing for the bill for the E/M (Evaluation and Management) services they provided.

Group Practice

Let’s say you happen to be part of an organization that has multiple practices in various locations operating independently and maintaining separate patient records. As long as the practices have the same tax identification number, they are considered to be part of a single group.

Moreover, in that case, there are more rules that determine whether a patient gets reported as new or established.

·      Single-Specialty Practice

If it’s a single-specialty practice and the patient hasn’t availed any services face-to-face from a physician from that practice in the past three years, that patient is reported as a new patient during medical billing.

Now, if within the next three years, that patient seeks some healthcare services again, but this time from a different physician, albeit from the same specialty practice, that patient gets reported as an established patient.

·      Multispecialty Practice

In the case of a practice that offers multiple specialties, within the same specialty, the same rules apply as mentioned above. However, if an established patient goes for any services to a physician from another specialty within the same practice, then that physician can report them as a new patient even if they’re using their established medical record.

·      Between Different Practices

Most of the time, when trying to differentiate between a new patient and an established patient, it’s important to consider who the patient is considered as new or established to.

For instance, if you change practices, join another organization, and some of your patients follow you there. While they may be new to that practice, they will be old patients to you, and therefore, they will be reported as established patients.

Importance of Distinguishing Between New Patient and Established PatientE/M Codes

As mentioned earlier, not being able to accurately distinguish between a new patient and established patient can lead to a lot of problems for healthcare practices. For starters, you wouldn’t be following coding guidelines, and this often results in denials and rejections of claims. You might have reported a patient as new when actually they fall under the established category.

Therefore, the insurance or paying company will reject your claim on that basis. Not only does this prolong your revenue cycle, but it also wastes a lot of time and effort as the billing process has to be reviewed and processed all over again.

Besides that, you want to report new patient and established patientE/M codes accurately so that you can be reimbursed fully. When it comes to E/M codes, the primary components you need to consider are the history, exam, decision-making, and time taken.

It is these key components and a few others that are used to calculate the RVUs (relative value units), or the RBRVS (resource-based relative value scale), which then determines the patient’s payment amount. Generally, new patient E/M codes tend to produce higher RVUs as they require more time and effort in their treatment and, therefore, result in more significant bills.

Consequently, when you report a new patient as an established patient, you tend to generate codes with lower RVUs and end up undercharging yourself. Additionally, in reality, it is incredibly hard to generate these codes and calculate accurate RVUs as a lot of factors go into consideration, and there isn’t always a fixed pattern to follow.

Conclusion

While advancements in the healthcare industry are making healthcare more accessible and pushing it to higher standards, they are also making medical billing and coding that much complicated. New patient and established patientE/M codes are no exception.

That’s why it’s crucial for healthcare professionals to work with a top-notch medical billing company that is well-acquainted with all coding guidelines and procedures and is proficient at procuring the full amount of payables for the healthcare practitioners.

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