In medical billing, determining whether a patient is new or established can be more complicated than it seems. When billing to an insurance carrier, specifying this difference can greatly impact how a claim is reimbursed. Here is a breakdown to help you distinguish between the two:

What makes a patient new?

Distinguishing a new patient may seem straightforward. However, a medical billing company will need to pay close attention to the circumstances regarding a patient’s past visits.

According to Nordian.com, a new patient is an “individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspeciality) within the previous 3 years”. In other words, when a patient comes in for their initial office visit, they are considered a new patient as long as a face-to-face E/M service has not been performed within 3 years. This means that even if the doctor reads a report or performs a non-E/M service for the patient, they will still be considered new for the office visit.

What makes a patient established?

Following the above logic, a patient seen for an E/M service within 3 years is considered established. This also applies to other physicians within the same group who share the same specialty or subspecialty. However, there are other scenarios to take into account.

• Scenario 1: If a doctor moves from one practice to another and sees the patient within three years of the last visit, the patient must be considered an established patient in the new practice.
• Scenario 2: If a covering physician sees an established patient from a particular doctor’s practice, the patient is considered to be established even though the covering physician may not have seen the patient before.
• Scenario 3: When a patient moves from one specialty to another specialty within a practice the established patient becomes a new patient.  An example would be a pediatric patient moving to a family practitioner within the same group.

For large practices with several specialties, it may be helpful to create a flowchart for determining new versus established patients. For more information and claim examples, visit Nordian Healthcare Solutions’ helpful guide.

Disclaimer: The materials contained on this website are provided for informational purposes only and do not constitute legal or other professional advice on any subject matter. Advanced Medical Practice Management does not accept any responsibility for any loss which may arise from reliance on information contained on this site.