{"id":9938,"date":"2019-10-15T09:04:43","date_gmt":"2019-10-15T03:34:43","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=9938"},"modified":"2025-05-09T13:03:17","modified_gmt":"2025-05-09T13:03:17","slug":"new-patient-vs-established-patient-em-codes","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/new-patient-vs-established-patient-em-codes\/","title":{"rendered":"New Patient vs Established Patient E\/M Codes"},"content":{"rendered":"<p style=\"text-align: justify;\">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.<\/p>\n<p style=\"text-align: justify;\">By CPT definition, a new patient is \u201cone 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.\u201d 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.<\/p>\n<ul style=\"text-align: justify;\">\n<li style=\"text-align: left;\">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.<\/li>\n<li style=\"text-align: left;\">A key to differentiating between new and established patients is understanding two terms used in CPT\u2019s definition of a new patient: \u201cprofessional services\u201d and \u201cgroup practice.\u201d<\/li>\n<li style=\"text-align: left;\">Medicare\u2019s definition of a new patient is slightly different than CPT\u2019s.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">The distinction between new and established patients applies only to the categories of evaluation and management (E\/M) services titled \u201cOffice or Other Outpatient Services\u201d and \u201cPreventive Medicine Services,\u201d 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.<\/p>\n<h2 style=\"text-align: justify;\">New Patient:<\/h2>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"59\">\u00a0<\/td>\n<td width=\"145\">\n<h3>History<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Exam<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Medical Decision Making<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Typical Face-To-Face Time (Minutes)<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99201<\/td>\n<td width=\"145\">Problem-focused<\/td>\n<td width=\"145\">Problem-focused<\/td>\n<td width=\"145\">Straightforward<\/td>\n<td width=\"145\">10<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99202<\/td>\n<td width=\"145\">Expanded problem-focused<\/td>\n<td width=\"145\">Expanded problem-focused<\/td>\n<td width=\"145\">Straightforward<\/td>\n<td width=\"145\">20<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99203<\/td>\n<td width=\"145\">Detailed<\/td>\n<td width=\"145\">Detailed<\/td>\n<td width=\"145\">Low<\/td>\n<td width=\"145\">30<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99204<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">Moderate<\/td>\n<td width=\"145\">45<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99205<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">High<\/td>\n<td width=\"145\">60<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2 style=\"text-align: justify;\">Established Patient:<\/h2>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"59\"><strong>\u00a0<\/strong><\/td>\n<td width=\"145\">\n<h3>History<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Exam<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Medical Decision Making<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Typical Face-To-Face Time (Minutes)<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99211<\/td>\n<td width=\"145\">Not required<\/td>\n<td width=\"145\">Not required<\/td>\n<td width=\"145\">Not required<\/td>\n<td width=\"145\">5<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99212<\/td>\n<td width=\"145\">Problem-focused<\/td>\n<td width=\"145\">Problem-focused<\/td>\n<td width=\"145\">Straightforward<\/td>\n<td width=\"145\">10<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99213<\/td>\n<td width=\"145\">Expanded problem-focused<\/td>\n<td width=\"145\">Expanded problem-focused<\/td>\n<td width=\"145\">Low<\/td>\n<td width=\"145\">15<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99214<\/td>\n<td width=\"145\">Detailed<\/td>\n<td width=\"145\">Detailed<\/td>\n<td width=\"145\">Moderate<\/td>\n<td width=\"145\">25<\/td>\n<\/tr>\n<tr>\n<td width=\"59\">99215<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">Comprehensive<\/td>\n<td width=\"145\">High<\/td>\n<td width=\"145\">40<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">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).<\/p>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"145\">\n<h3>Office Visit Rus<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>New Patients (99201\u201399205)<\/h3>\n<\/td>\n<td width=\"145\">\n<h3>Established Patients (99211\u201399215)<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"145\">Level I<\/td>\n<td width=\"145\">0.95<\/td>\n<td width=\"145\">0.56<\/td>\n<\/tr>\n<tr>\n<td width=\"145\">Level II<\/td>\n<td width=\"145\">1.7<\/td>\n<td width=\"145\">0.99<\/td>\n<\/tr>\n<tr>\n<td width=\"145\">Level III<\/td>\n<td width=\"145\">2.52<\/td>\n<td width=\"145\">1.39<\/td>\n<\/tr>\n<tr>\n<td width=\"145\">Level IV<\/td>\n<td width=\"145\">3.59<\/td>\n<td width=\"145\">2.17<\/td>\n<\/tr>\n<tr>\n<td width=\"145\">Level V<\/td>\n<td width=\"145\">4.58<\/td>\n<td width=\"145\">3.18<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Another important difference between the codes is that the new patient codes (99201\u201399205) require that all three key components (history, exam, and medical decision making) be satisfied, while the established patient codes (99211\u201399215) 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).<\/p>\n<p style=\"text-align: justify;\">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.<\/p>\n<p style=\"text-align: justify;\">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.<\/p>\n<h2><strong>FAQs<\/strong><\/h2>\n<h3 style=\"text-align: justify;\">Reference:<\/h3>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/www.aafp.org\/fpm\/2003\/0900\/p33.html\">Understanding When to Use the New Patient E\/M Codes<\/a><\/p>\n<p>\u00a0<\/p>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1746795401224\"><strong class=\"schema-faq-question\"><strong>1. How does CPT define a new patient?<\/strong><\/strong> <p class=\"schema-faq-answer\">According to CPT, a new patient is someone who has not received professional services from the physician or another physician of the same specialty in the same group practice within the last three years.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1746795452555\"><strong class=\"schema-faq-question\"><strong>2. What is the difference between a new and an established patient?<\/strong><\/strong> <p class=\"schema-faq-answer\">A new patient has not seen the physician or another physician of the same specialty in the same group practice in the past three years. An established patient has received services from the same physician or a similar one in the same group within the last three years.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1746795593233\"><strong class=\"schema-faq-question\"><strong>3. Why is it important to distinguish between new and established patients?<\/strong><\/strong> <p class=\"schema-faq-answer\">Distinguishing between new and established patients is important for coding accuracy and appropriate reimbursement. New patient visits often require more time and documentation, leading to higher reimbursement rates.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1746795624783\"><strong class=\"schema-faq-question\"><strong>4. What are the key components for coding new patient visits?<\/strong><\/strong> <p class=\"schema-faq-answer\">For new patient visits, all three key components must be documented: history, exam, and medical decision-making. For established patients, only two of these three components are required.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1746795669520\"><strong class=\"schema-faq-question\"><strong>5. How is coding different for new and established patient visits?<\/strong><\/strong> <p class=\"schema-faq-answer\">New patient codes (99201\u201399205) require more comprehensive documentation, and the RVUs are generally higher than those for established patient visits (99211\u201399215) at the same level of care.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":12528,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[1973,1974,1975,1976,1977,1966,1978,192,1979,1980,1981,1982,1983,815,1984],"class_list":["post-9938","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-avoid-billing-risks-for-new-vs-established-patients","tag-correct-coding-established-vs-new-patient","tag-cpt-codes-for-evaluation-and-management","tag-cpt-coding-and-e-m-documentation","tag-determining-new-or-established-patient-codes","tag-evaluation-and-management-services-guide","tag-guidelines-for-determining-new-vs-established-patient","tag-medicare-medicaid-services","tag-new-patient-vs-established-patient-em-services","tag-new-patient-vs-established-patient-visit","tag-new-patient-vs-established-patient-selection-assistance","tag-new-vs-established-patient","tag-new-vs-established-patients","tag-outsourced-medical-billing-company","tag-understanding-when-to-use-the-new-patient-e-m-code"],"yoast_head":"<!-- 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How does CPT define a new patient?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"According to CPT, a new patient is someone who has not received professional services from the physician or another physician of the same specialty in the same group practice within the last three years.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/new-patient-vs-established-patient-em-codes\\\/#faq-question-1746795452555\",\"position\":2,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/new-patient-vs-established-patient-em-codes\\\/#faq-question-1746795452555\",\"name\":\"2. What is the difference between a new and an established patient?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"A new patient has not seen the physician or another physician of the same specialty in the same group practice in the past three years. 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