When a patient is seen for the first time in an in-hospital setting (the patient's primary care physician has not seen the patient in the office), is the patient considered a new patient when he/she follows up in the office after discharge? ...
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Article Overview
This short coding guidance article addresses how to determine whether a patient is treated as new or established for Evaluation and Management purposes when the first encounter occurred in an in-hospital setting and follow-up occurs in the office after discharge. It is relevant to physicians, coders, and billing staff who need to understand patient-status rules across settings and related E/M documentation and coding considerations.
Why This Topic Matters
Accurate patient-status selection affects office E/M code assignment and helps avoid coding errors when care spans hospital and office settings.
What You Will Learn
- How patient status is evaluated across inpatient and office settings
- What factors are considered when distinguishing new versus established patients for E/M coding
- How prior professional services affect patient classification over a three-year period
- Why place of service alone does not determine patient status
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Practice administrators
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