Policy No: 101
Originally Created: 10/01/2008
Last Reviewed: 03/01/2019
Last Revised: 03/01/2019
This policy applies only to physicians and other qualified health care professionals.
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).
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|
American Medical Association, Current Procedural Terminology (CPT®) Chicago, AMA Press.
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.
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