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Definition of New Patient for Billing Evaluation and Management Services

NGS has seen an increase in claim denials for "'New Patient' qualifications were not met." 

CMS interprets the phrase "new patient" to mean a patient who has not received any professional services, i.e., E&M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

Example: If a professional component of a previous procedure is billed in a three-year time-period, e.g., a lab interpretation is billed and no E&M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. 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. 

In 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E&M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26. (597 KB)

An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.

No distinction is made between new and established patients in the emergency department. E&M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Definition of New Patient for Billing Evaluation and Management Services
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