CHPW would like to provide clarification on how to determine when to use the evaluation and management (E/M) code for “new patient” vs. when to use the code for “established patient.”
A new patient is one who has not received any face-to-face professional services from the provider or another provider of the exact same specialty and subspecialty in the same group practice, within the past three years.
An established patient is one who has received face-to-face professional services from the provider or another provider of the exact same specialty and subspecialty in the same group practice, within the past three years.
Physician assistants and advanced practice nurses who are working with physicians are considered as working in the exact same specialty and exact same subspecialty as the physician.
At CHPW, specialty and subspecialty are determined by the provider taxonomy that is set up in our claims system. That may be different compared to the taxonomy submitted on the claim.
If a provider is on call for or covering for another provider, classify the patient’s encounter as if it would have been by the original provider (the one who is not available).
CHPW has in place a Claims Edit System (CES) that identifies these scenarios and denies claims that have an incorrect patient status code. Note that professional services include services performed in emergency settings and once initial care is established in the ER, the patient is considered an established patient for any follow up services performed by the same provider or group.
This is supported by the Medicare Claims Processing Manual and the current CPT® Professional Edition, Principles of CPT® Coding, which states: “This rule identifies when the patient claims history indicates the patient has been seen by the same provider within 3 years of the current claim line’s beginning date of service. An established patient evaluation and management (E/M) code should be reported instead of the new patient E/M code.”
If you receive this denial, submit a corrected claim with an established E/M code to resolve the denial.
If you have any questions about new or established patient codes, please contact [email protected].
If you have any questions about or changes to your taxonomy, please contact [email protected].