New Patients And Old Patients – Medical Billing Differences

New Patients And Old Patients – Medical Billing Differences

There is a lot of confusion in many physician’s offices on how to handle the coding & medical billing of services rendered to an old patient and a new patient.

New patient medical billing requires a lot more work than an established patient and this is reflected in the new coding requirements as well as reimbursement for your medical billing. One key to differentiating between new and established patients is understanding two terms used in CPT’s definition of a new patient: “professional services” and “group practice” and the understanding that Medicare’s definition of a new patient is slightly different than CPT’s.

According to CPT’s definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” A long definition to be sure but it should help narrow down which coding to use. If you are handling a medical billing claim and the patient has been seen by a different physician and received professional services from another physician in the same group and the same specialty within the prior three years they are an established patient.

This distinction is only to be used when handling medical billing claims in the realm of evaluation and management (E/M) services titled “Office or Other Outpatient Services” and “Preventive Medicine Services”.

The key differences for learning to distinguish new patients from established patients is that it will enable a practice to be reimbursed for additional work they may have been missing getting reimbursed on their medical bill for services rendered.
For example, a visit that produces a detailed history of a patient, a detailed exam is performed and decision making of low complexity qualifies as a level-IV visit if the patient is established and a level-III visit if the patient is new. Under the criteria established by CPT the established patient visit amounts to 2.17 RVUs ($79.82), while the new patient visit amounts to 2.52 RVUs ($92.69) on your Medicare form.

View all Articles by: Melissa Clark, CCS-P