College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP

When is a Patient a "New" Patient?

Evaluation and Management Services are divided into broad categories, including office visits, hospital visits and consultations.   Most are further divided in to subcategories  - the new patient and the established patient.  Proper assessment of  the patient's status is essential to accurately assigning the appropriate CPT  (Current Procedural Terminology) code.

Documentation

Where CPT distinguishes between "new" and "established" patients,  the standard of support for "new" patients is higher.    Generally, all three of the key components - history, examination and medical decision making are considered in determining the descriptor for the level of E/M service for a new patient.   Established patients generally require only using two of the three to determine the descriptor.  The exception is when visits consist predominantly of counseling or coordination of care.

Specific Guidelines Apply To Specialties

The Evaluation and Management Services Guidelines in the CPT manual state:

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.

Since new visits are reimbursed at a higher rate than established visits, HCFA determines the recognized specialties.  The list can be found in Section 2207 B of the Medicare Carrier's Manual.   Please be aware that some subspecialty distinctions are not recognized, so not all visits typically considered new will qualify.  The recognized specialties are:

Addiction Medicine Allergy/Immunology Anesthesiology Cardiac Surgery Cardiology Chiropractic Colorectal Surgery Critical Care (Intensivists) Dermatology Diagnostic Radiology Emergency Medicine Endocrinology Family Practice Gastroenterology General Practice General Surgery Geriatric Medicine Gynecological/Oncology Hand Surgery

Hematology Hematology/Oncology Infectious Disease Internal Medicine Interventional Radiology Maxillofacial Surgery Medical Oncology Multispecialty Clinic or Group Practice Nephrology Neurology Neuropsychiatry Neurosurgery Nuclear Medicine Obstetrics and Gynecology Ophthalmology Optometry Oral Surgery (dentists only) Orthopedic Surgery Otolaryngology

Pathology Pediatric Medicine Peripheral Vascular Disease Physical Medicine and Rehabilitation Plastic and Reconstructive Surgery Podiatry Preventive Medicine Psychiatry Pulmonary Disease Radiation Oncology Rheumatology Surgical Oncology Thoracic Surgery Unknown Physician Specialty Urology Vascular Surgery

(Osteopathic references have been omitted for brevity.)

The CPT manual offers further  clarification:

In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.

No distinction is made between new and established patients in the emergency department.  E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Do the same rules apply to consultations?  Can they only be between the specialties listed above?

No,  consultations are governed by a separate set of rules.   In fact, our next tip-of the-week will discuss the new Medicare instructions for billing consultations issued this month (August, 1999).

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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