New Vs Established Patient

I. Definitions

• A new patient is one who has not received any professional services (ie, those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s)) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
• An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

II. Examples:

• New Patient
  A newborn comes to your practice for her first encounter from the birth hospital where your group does not have hospital privileges.
  
  A 7-year old patient returns to your practice. The last face-to-face professional service was a little over 3 years ago. A little over 2 and half years ago you called in a refill for this patient’s allergy medication. (Teaching point: Calling in a prescription does not define a professional service.)
  
  You are in a multi-specialty clinic. The patient was seen by a pediatrician, but you are board certified in a pediatric subspecialty and are credentialed with the payers that way. No one in your subspecialty has ever seen this patient.
  
  You are a pediatric cardiologist and are asked to read and review an EKG for a pediatric patient. You read it (bill for the reading) and call the pediatrician to have the patient follow up with you for care. The patient presents to your office for the first time (not a consultation). (Teaching point: Reading and billing for an EKG does not count as a professional service.).
• Established Patient
  A newborn comes to your practice for the first encounter with a pediatrician after discharge from the birth hospital. One of your pediatricians rounded on the baby in the hospital. (Teaching point: Location of service will not matter, a professional service occurred within 3 years so they are established.)
  
  You are covering for a pediatrician who is out of town for a few days. You have a coverage arrangement with the pediatrician who is out of town. An established patient of his comes to see you. (Teaching point: When you are covering for another pediatrician and his patient sees you, you code based on their establishment with the unavailable physician – if the patient is established to them, the patient is established to you.)
  
  A pediatrician leaves one group practice and joins another pediatric group. Some of her patients follow her to the new practice. One of the patients who followed was established to the pediatrician presents to the new practice, and sees one of the pediatricians. (Teaching point: Because the patient is considered established to the new pediatrician, that patient is considered established to all physicians in that new practice who are of the same specialty and subspecialty. A change in address, tax ID or physical location will not matter.)
  
  A patient presents to the pediatrician in the office. Her only visit previous was performed by the nurse practitioner. (Teaching point: A patient is established if she has seen a nurse practitioner because the nurse practitioner takes on the same specialty as the physician practice).