Understanding when to use the new patient E/M codes.

N ew patient visits used to be easy to distinguish from those with established patients. A new patient was someone you had not previously seen or perhaps someone for whom you did not have a current medical record. Today, like so many other aspects of health care delivery, differentiating between new and established patients and coding your services accordingly has become more complex. By CPT definition, a new patient is " one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. " By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years. The distinction between new and established patients applies only to the categories of evaluation and management (E/M) services titled " Office or Other Outpatient Services " and " Preventive Medicine Services, " but as a family physician, most of the codes you submit fall into these categories, and the definition is hard to incorporate into your coding habits. This article will explain why the difference matters and describe an approach you can use to make the definition easier to apply. The key differences The reason for learning to distinguish new patients from established patients, apart from following coding guidelines, is that it enables you to be reimbursed for the additional work that new patient visits require (see " Documentation requirements " on page 34). For the new patient codes, the required components and the relative value units (RVUs) are greater than for established patient codes at the same level (see " Office visit RVUs " on page 35). So in some cases, not distinguishing new patients from established patients amounts to shortchanging yourself. For example, a visit that produces a detailed history, detailed exam and decision making of low complexity qualifies as a level-IV visit if the patient is established and a level-III visit if the patient is new. The established patient visit amounts to 2.17 RVUs ($79.82), while the new patient visit amounts to 2.52 RVUs ($92.69). Another important difference between the codes is that the new patient codes (99201-99205) require that all three key components (history, exam and medical decision making) be satisfied, while the established patient codes (99211-99215) require that only two of the three key Emily …