May Coding Q&A: If a Patient is Being Seen for a New Problem, Should They be Billed as a New Patient?

May 29, 2018

Got coding questions? Your Academy has the answers. Each month we feature a member’s question with an answer provided by AAPM&R’s Reimbursement and Policy Review Committee (RPRC).

Q: If a patient is being seen for a new problem, should they be billed as a new patient?

A: Not necessarily – it depends on when the patient was last seen by you or someone else in your practice. Per the CPT codebook, 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 who belongs to the same group practice, within the past 3 years.

Further, professional services are defined as those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s). Therefore, if the patient has had a procedure or test (for example, any injection or EMG) performed by you or another physician/qualified health care professional of the exact same specialty who belongs to the same group practice, within the last 3 years (including face-to-face interaction with the physician), this patient is considered an established patient. The patient’s new presenting problem does not impact the patient’s status as new or established.

The CPT codebook includes a decision tree to assist providers and coders in identifying whether a patient is new or established. This tree can be found on page 5 of the 2018 CPT codebook.  

Find additional resources related to reimbursement here. Do you have a coding or billing question? Contact AAPM&R at codingquestions@aapmr.org for assistance. 

Accurate coding is the responsibility of the provider. This article is intended only as a resource to assist in the billing process.