The definitions of new or established patients relate to services from a physician or qualified healthcare professional licensed from the same specialty and subspecialty in the same group practice.
A new patient is defined as someone who has not received professional services from the practice in the past three years. The criteria for a new patient visit involve much more than an established patient visit.
Likewise, if the patient has been seen in the practice for that specific specialty in the past three years, they must be billed as an established patient.
New versus established are distinctions only used in the office setting. Any emergency room visit is always considered a new patient, as obtaining a complete medical history is critical for diagnosing and treating patients in an urgent setting.
New Patient CPT Codes:
It is required to meet all three principal components (History, Examination, and Medical Decision-making)
99201:
- History: Problem-focused
- Examination: Problem-focused
- Medical Decision-making: Straightforward
- Average Face-to-Face Time: 10 minutes
99202:
- History: Expanded Problem-focused
- Examination: Expanded Problem-focused
- Medical Decision-making: Straightforward
- Average Face-to-Face Time: 20 minutes
99203:
- History: Detailed
- Examination: Detailed
- Medical Decision-making: Low
- Average Face-to-Face Time: 30 minutes
99204:
- History: Comprehensive
- Examination: Comprehensive
- Medical Decision-making: Moderate
- Average Face-to-Face Time: 45 minutes
99205:
- History: Comprehensive
- Examination: Comprehensive
- Medical Decision-making: High
- Average Face-to-Face Time: 60 minutes
Established Patient CPT Codes:
It is required to meet two of the three key components.
99211:
- History: Not Required
- Examination: Not Required
- Medical Decision-making: Not Required
- Average Face-to-Face Time: 5 minutes
99212:
- History: Problem-focused
- Examination: Problem-focused
- Medical Decision-making: Straightforward
- Average Face-to-Face Time: 10 minutes
99213:
- History: Expanded problem-focused
- Examination: Expanded problem-focused
- Medical Decision-making: Low
- Average Face-to-Face Time: 15 minutes
99214:
- History: Detailed
- Examination: Detailed
- Medical Decision-making: Moderate
- Average Face-to-Face Time: 25 minutes
99215:
- History: Comprehensive
- Examination: Comprehensive
- Medical Decision-making: High
- Average Face-to-Face Time: 40 minutes
Clarifications and Exceptions
Evaluation and management of a patient that has been referred for treatment recommendations may result in higher reimbursement by billing consultation codes as opposed to new patient codes, but not for Medicare patients. Medicare has stopped recognizing consultation codes due to misuse of the higher paying service codes in the past.
New patient and established patient codes are based on face-to-face services. It is important to remember that if you have provided a professional service, such as reading an x-ray, interpreting a lab, or calling in a prescription to get the patient through until the first visit to the office, a new patient visit code is acceptable, as the previous service was not face-to-face.
As defined above, once a patient has been seen and designated an established patient (in a three-year period), they remain established no matter what their insurance status. If a patient simply changes insurance companies, they are not considered a new patient again.
When a physician moves to another practice, some established patients may follow him/her. The transferring patients will still be considered established patients at the new practice if the physician has billed any face-to-face services for them in the past three years. This code distinction remains true whether or not the medical records for that patient have been transferred to the new practice.
Likewise, if another physician in the old practice takes over patients that did not follow him/her to the new practice, established patient codes must also still be used, as the “new” physician is providing services of the same specialty and in the same practice as had been billed in the previous three years.