New Patient Visit

Policy No: 101
Originally Created: 10/01/2008
Section: Medicine
Last Reviewed: 04/01/2024
Last Revised: 04/01/2023
Approved: 04/11/2024
Effective: 05/01/2024
Policy applies to: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified health care professionals.

Evaluation and Management (E&M) Services – Current Procedural Terminology (CPT®) makes a distinction between a new patient and an established patient by having separate codes for each (e.g., office visits are separated into new patient codes and established patient codes).

Professional Services – E&M service or other face-to-face service(s)

Same Group Practice – Same federal tax identification number.

New patient E&M visit codes are eligible for reimbursement only when the patient has not received any professional services within the last three years from the same physician or other qualified healthcare professional; or another physician or other qualified healthcare professional of the same specialty and subspecialty, as defined by the National Uniform Claim Committee taxonomy codes or identified during the credentialing process, who belongs to the same group practice. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician.

If physician has seen the patient within the last three years, then joins a different group practice or goes to a private practice and the patient follows, the physician should assign an established E&M code for the services provided.

If the primary physician has seen the patient within the last three years, the on-call or covering physician should not assign a new patient E&M for the visit. The physician on-call or covering for another physician, should assign an established E&M code for the services provided.

When new patient E&M visit codes are deemed ineligible for reimbursement as outlined above, our health plan at its discretion will either:

• Deny the code with a message code indicating the provider should rebill with a more appropriate E&M code, or
• Change the submitted second new patient E&M visit code to an established E&M visit code as follows:

American Medical Association, Current Procedural Terminology (CPT®) Chicago, AMA Press

National Uniform Claim Committee Taxonomy Codes

Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.A

Noridian Medicare, New Patient vs Established Patient Visit, October 26, 2018

Correct Coding Guidelines