Seems I have had a larger than usual amount of inquiries regarding the “rules” of billing for a “New Patient Visit” vs “Established Patient”.  Medicare is very clear on their interpretation of this.

WPS (Medicare) has enhanced their claims editing software with respect to new and established patients. Their policies apply the AMA (American Medical Association) and E/M (Evaluation and Management) guidelines. You run the risk of denial if you fail to follow these guidelines.  Likewise, if any of your claims have passed their edits, in error, you run the risk of post audit and refund requests.

Per AMA guidelines, a new patient is defined as “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care profession of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.”

Often times, questions arise when advanced practice nurses and physician assistants are working with a physician.  These professionals are considered as working in the same subspecialties as the physician.  The 3 year rule still applies.

If you have questions related to this policy, please refer to the guidelines and decision tree referenced in the 2017 CPT Professional Edition.

As your Medical Billing Company, providing end-to-end Revenue Cycle Management Services, you can also direct any questions by calling us at 573.634.7155.