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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 code Established patient replacement code
92002 92012
92004 92014
99201 99212
99202 99213
99203 99214
99204 99215
99205 99215
99324 99334
99325 99335
99326 99336
99327 99337
99328 99337
99341 99347
99342 99348
99343 99349
99344 99350
99345 99350
99381 99391
99382 99392
99383 99393
99384 99394
99385 99395
99386 99396
99387 99397
G0466 G0467
G0469 G0470
S0610 S0612
S0620 S0621

 

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.

Cross References

Correct Coding Guidelines

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.