April 2, 2015

New and Established Patients – Understanding When to Use Patient E/M Codes

According to the Current Procedural Terminology (CPT^®) codebook, there are two subcategories of office visits: new patient and established patient. Recently, Blue Cross and Blue Shield of Oklahoma (BCBSOK) has received a number of claims where new patient codes are billed repeatedly for the same patient.

• A new patient is defined as one who has not received any professional services from the physician or qualified health care professional, or another physician of the same specialty and subspecialty who belongs to the same group practice, within the past three years.

• An established patient is defined as one who has received professional services from the physician or qualified health care professional of the same specialty or sub-specialty who belong to the same group practice, within the past three years.

It is important to note that selecting the appropriate level of Evaluation and Management (E/M) codes when rendering services for new and established patients also requires key components, such as an expanded or problem-focused history or examination, and medical decision-making. For more information to help ensure you are reporting correctly, such as details on E/M service guidelines and clarification, refer to the American Medical Association (AMA) CPT codebook.

Fraud Awareness
As a reminder, BCBSOK has the right to conduct audits or reviews of claims submitted by health care providers, which may include, but are not limited to, requesting medical records and refunds as the result of inappropriate payments made on behalf of our members. If you suspect or need to report any form of medical identify theft or fraud, you may contact BCBSOK, 24 hours a day, seven days a week by calling the Fraud Hotline at 877-272-9741. You may remain anonymous, as all calls and online reports are confidential.

CPT Copyright 2014 AMA. All rights reserved. CPT is a registered trademark of the AMA.

This material is for educational purposes only and is not intended to be a definitive source for what codes should be used for submitting claims for any particular disease, treatment or service. Health care providers are instructed to submit claims using the most appropriate code based upon the medical record documentation and coding guidelines and reference materials.