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.
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