Medical Billing Services

New Patient vs Established Patient E/M Codes

New patient visits used to be easy to distinguish from those with established patients. A new patient was someone you had not previously seen or perhaps someone for whom you did not have a current medical record. Today, like so many other aspects of health care delivery, differentiating between new and established patients and coding your services accordingly has become more complex.

By CPT definition, a new patient is “one 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.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years.

  • New patient visits require more work than established patient visits at the same level, and this is reflected in the coding requirements as well as the reimbursement for new patient visits.
  • A key to differentiating between new and established patients is understanding two terms used in CPT’s definition of a new patient: “professional services” and “group practice.”
  • Medicare’s definition of a new patient is slightly different than CPT’s.

The distinction between new and established patients applies only to the categories of evaluation and management (E/M) services titled “Office or Other Outpatient Services” and “Preventive Medicine Services,” but as a family physician, most of the codes you submit fall into these categories, and the definition is hard to incorporate into your coding habits. This article will explain why the difference matters and describe an approach you can use to make the definition easier to apply. The reason for learning to distinguish new patients from established patients, apart from following coding guidelines, is that it enables you to be reimbursed for the additional work that new patient visits require. Documentation requirements are added for more detailed information.

New Patient:

 

History

Exam

Medical Decision Making

Typical Face-To-Face Time (Minutes)

99201 Problem-focused Problem-focused Straightforward 10
99202 Expanded problem-focused Expanded problem-focused Straightforward 20
99203 Detailed Detailed Low 30
99204 Comprehensive Comprehensive Moderate 45
99205 Comprehensive Comprehensive High 60

Established Patient:

 

History

Exam

Medical Decision Making

Typical Face-To-Face Time (Minutes)

99211 Not required Not required Not required 5
99212 Problem-focused Problem-focused Straightforward 10
99213 Expanded problem-focused Expanded problem-focused Low 15
99214 Detailed Detailed Moderate 25
99215 Comprehensive Comprehensive High 40

For the new patient codes, the required components and the relative value units (RVUs) are greater than for established patient codes at the same level. So in some cases, not distinguishing new patients from established patients amounts to shortchanging yourself. For example, a visit that produces a detailed history, detailed exam and decision making of low complexity qualifies as a level-IV visit if the patient is established and a level-III visit if the patient is new. The established patient visit amounts to 2.17 RVUs ($79.82), while the new patient visit amounts to 2.52 RVUs ($92.69).

Office Visit Rvus

New Patients (99201–99205)

Established Patients (99211–99215)

Level I 0.95 0.56
Level II 1.7 0.99
Level III 2.52 1.39
Level IV 3.59 2.17
Level V 4.58 3.18

Another important difference between the codes is that the new patient codes (99201–99205) require that all three key components (history, exam and medical decision making) be satisfied, while the established patient codes (99211–99215) require that only two of the three key components be satisfied. Because the criteria for coding problem-oriented new patient visits are more stringent, there are also cases where the same service components would yield an established patient code with more RVUs than the appropriate new patient code. For example, a visit that includes an expanded problem-focused history, detailed problem-focused exam and moderate complexity decision making would qualify as a level-II new patient visit (1.70 RVUs) but a level-IV established patient visit (2.17 RVUs).

Problem-oriented encounters for both new and established patients can also be coded based on the total time spent with the patient if counseling/coordination of care constitutes more than 50 percent of the total encounter time. The times associated with the new patient services, however, are higher than for the established patient encounters.

Preventive medicine encounters all require a comprehensive history and exam, and the codes are selected according to the age of the patient. The RVUs vary according to the level of physician work associated with performing comprehensive evaluations for the different age ranges.

Reference:

Understanding When to Use the New Patient E/M Codes

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