Q & A: What is the Definition of "New Patient" for Billing Evaluation and Management (E/M) Services?

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Aug 26th, 2014 - Reviewed/Updated Aug 9th

Q: What is the definition of "new patient" for billing evaluation and management (E/M) services?

A: Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf).

You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.