Coding for New vs. Established Patients
Authors: The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Trisha Malisch, CCS-P, CPC; Steve Rad, MD, FACOG.
A long-standing rule in the world of coding is the definition of new and established patients for the purpose of assigning office/other outpatient Evaluation and Management codes.
The CPT manual states that a new patient is one who has not received any 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.
The SMFM Coding Committee is often asked for assistance on what services are considered in the designation of new versus established patient.
Fortunately, the CPT manual also contains the definition of professional services. “Professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services.”[1]
Services that do not require face-to-face encounters do not establish a patient. This includes ultrasound and other diagnostic testing.
According to CMS, “An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”[2]
[1] American Medical Association, CPT® Evaluation and Management (E/M) Code and Guideline Changes, Page 3 (https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf)
[2] Centers for Medicaid and Medicare Services, Medicare Claims Processing Manual, Page 38 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf)