New Patient Visit

Policy No: 101
Originally Created: 10/01/2008
Section: Medicine
Last Reviewed: 03/01/2019
Last Revised: 03/01/2019
Approved: 03/07/2019
Effective: 05/01/2019

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

Definitions

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).

Policy statement

New patient E&M visit codes are eligible for reimbursement only when the patient has not received any professional services (i.e., E&M service or other face-to-face service) within the last three years from the physician or another physician of the same specialty and subspecialty, as defined by the National Uniform Claim Committee taxonomy codes, who belongs to the same group practice.

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:
New patient E&M visit codes
New patient codeEstablished patient replacement code
9200292012
9200492014
9920199212
9920299213
9920399214
9920499215
9920599215
9932499334
9932599335
9932699336
9932799337
9932899337
9934199347
9934299348
9934399349
9934499350
9934599350
9938199391
9938299392
9938399393
9938499394
9938599395
9938699396
9938799397
G0466G0467
G0469G0470
S0610S0612
S0620S0621

References

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

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.