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New vs. Established Patients

Created: 1/1/13 | Updated: 02/26/2015
CPT 2012 included updates to the evaluation and management (E/M) guidelines to clarify the meaning of “new” vs. “established” patients. By CPT definition…
• A new patient is “one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

• Professional Service = CPT defines “professional service” as “those face-to-face services rendered by a physician and reported by a specific CPT code(s)”.

• An established patient has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the prior three years.


Question: Does an EEG interpretation being done prior to an E&M make the patient new or established?

Answer: If a professional component of a previous procedure is billed in a 3 year time period, e.g., EEG 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.

Example: The Physician performed a professional interpretation of an x-ray for a patient last year. Other than that, the Physician has had no encounter with this patient. Today, the patient is seen in the Physician's office for the first time. This would be considered a new patient because an interpretation of a diagnostic test, reading of clinical labs, or EKGs in the absence of a face-to-face encounter does not affect the new patient designation.

Example: A primary-care physician recommends that a 60-year-old female see an oncologist. One of the Oncology physicians interpreted some test results for the same patient the previous year but provided no face-to-face service.  In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within the Oncology practice provided the patient with a face-to-face service within the past three years.