New vs Established
Patient Guide

A new patient is one who has NOT received any professional services from the physician or qualified health professional (QHP), or another physician of the same specialty in the same group practice, within the past three years.

An established patient is one who HAS received professional services from the physician or QHP, or another physician of the same specialty in the same group practice, within the past three years.

The determination is made at the time of the encounter, based on the patient's history with the practice, not the patient's history with a specific physician.

The three-year rule is the core determinant of new vs established status. It looks backward three years from the date of the current encounter.

If the patient received ANY professional service (face-to-face or non-face-to-face) from the physician/QHP or another physician of the same specialty in the same group within the past three years, the patient is ESTABLISHED.

If the patient has NOT received any professional service from the physician/QHP or another physician of the same specialty in the same group within the past three years, the patient is NEW.

The three-year clock resets from the date of the last professional service. A patient who was seen three years and one day ago is considered NEW again.

Professional services include E/M services, procedures, consultations, and any other service billed by the physician/QHP. They do NOT include facility services (e.g., hospital room and board) or services billed by the facility.

Professional services are services billed by a physician or QHP on a CMS-1500 claim form. These are the services that determine new vs established status.

Professional services include: office visits (E/M), hospital visits (E/M), consultations, procedures (surgical and medical), diagnostic services (professional component), and any other service billed by the physician/QHP.

Professional services do NOT include: facility services (room and board, nursing care), technical component of diagnostic services (unless billed by the physician), or services provided by non-physician staff under general supervision (unless billed under the physician's NPI).

If a physician bills the professional component of a diagnostic test (e.g., EKG interpretation, radiology read), that counts as a professional service and establishes the patient as established for future encounters.

Services provided by NP, PA, CNS, or CNM are treated as services of the physician for new vs established purposes, IF billed under the physician's NPI (incident-to billing) or under the NP/PA's own NPI within the same specialty and group.

The new vs established determination considers the physician's specialty as sub-specialized by the CMS physician specialty codes. If a physician in the same group practice has the same specialty, the patient is established.

If a physician in the same group practice has a DIFFERENT specialty, the patient may be NEW to that physician even if seen by another physician in the group within three years.

Example: A patient seen by a cardiologist in a multi-specialty group is NEW to a dermatologist in the same group, unless the dermatologist also provided professional services within three years.

Sub-specialties within the same primary specialty (e.g., cardiology and interventional cardiology) may be treated as the same specialty or different specialty depending on the CMS specialty code. Check the CMS physician specialty codes.

For physicians with multiple specialties, use the specialty that matches the service provided at the current encounter.

If the specialty is ambiguous, default to the primary specialty listed on the physician's enrollment. Document the rationale for the new vs established determination.

New patient E/M codes (99202-99205) are HIGHER paying than established patient E/M codes (99212-99215) for the same level of service. This reflects the additional work of a new patient encounter (full history, full examination, higher medical decision-making).

New patient E/M codes require all three key components (history, examination, medical decision-making) meet or exceed the level for the code selected. Established patient E/M codes require only two of three key components.

New patient codes: 99202 (straightforward), 99203 (low), 99204 (moderate), 99205 (high). These require a medically appropriate history and exam and a straightforward-to-high level of medical decision-making.

Established patient codes: 99212 (straightforward), 99213 (low), 99214 (moderate), 99215 (high). These require a medically appropriate history and exam and a straightforward-to-high level of medical decision-making.

For 2021+ office E/M codes, the level is determined by medical decision-making (MDM) or total time. The history and exam are not used to determine the code level, but must be medically appropriate for the service.

Using a new patient code when the patient is established (or vice versa) is a common coding error that results in denials or overpayments.

Document the new vs established status in the medical record. For new patients, document the date of the first encounter and confirm no prior professional services within three years.

For established patients, reference the prior encounter date(s) and the physician who provided the prior service(s). This supports the established status.

Document the chief complaint, history, examination, and medical decision-making as required for the E/M code level selected.

For time-based coding, document the total time spent on the encounter (including review of records, examination, counseling, documentation, and coordination of care).

For specialty-specific encounters (e.g., same group, different specialty), document the specialty of the current physician and the prior physician, and the rationale for the new vs established determination.

If the patient was seen by a physician who has since left the practice, the patient may still be established if the physician was in the same group and same specialty at the time of the prior service.

For 2021+ office E/M codes, the level of MDM determines the code level. MDM has three elements: (1) number and complexity of problems addressed, (2) amount and/or complexity of data reviewed and analyzed, and (3) risk of complications, morbidity, mortality, or patient management.

To select a code level, two of the three MDM elements must meet or exceed the level for the code selected.

New patient codes (99202-99205) and established patient codes (99212-99215) use the SAME MDM framework. The difference is in the history/exam requirements and the payment, not the MDM.

Level 2 (99202/99212): Straightforward MDM — minimal problems, minimal data, minimal risk.

Level 3 (99203/99213): Low MDM — low problems, low data, low risk.

Level 4 (99204/99214): Moderate MDM — moderate problems, moderate data, moderate risk.

Level 5 (99205/99215): High MDM — high problems, high data, high risk.

For 2021+ office E/M codes, you may select the code level based on total time instead of MDM. Total time includes all time spent by the physician/QHP on the encounter, including non-face-to-face time.

Total time includes: review of records before the encounter, the face-to-face encounter (examination, counseling, discussion), documentation, and coordination of care (ordering tests, reviewing results, communication with other providers).

New patient time thresholds: 99202 (15-29 min), 99203 (30-44 min), 99204 (45-59 min), 99205 (60-74 min).

Established patient time thresholds: 99212 (10-19 min), 99213 (20-29 min), 99214 (30-39 min), 99215 (40-54 min).

New patient codes have HIGHER time thresholds than established patient codes for the same level. This reflects the additional time for a new patient encounter (full history, full examination, higher complexity).

Document the total time spent on the encounter, including a breakdown of activities if the time is used for code selection. Do not include time spent by clinical staff or time for services separately reported.

CO-16 (incorrect new vs established code) — using a new patient code for an established patient or vice versa. Fix: verify the patient's status and use the correct code set.

CO-11 (diagnosis inconsistent with new patient E/M) — the diagnosis does not support the level of new patient E/M. Fix: correct the diagnosis code to support the service.

CO-50 (not medically necessary) — the new patient E/M is not deemed medically necessary. Fix: appeal with documentation of medical necessity and the clinical content of the visit.

CO-97 (bundling) — the new patient E/M is bundled into another service (e.g., surgery). Fix: use modifier 25 for a significant, separately identifiable E/M on the same day as a procedure.

CO-24 (not a covered benefit) — the payer does not cover new patient E/M for the specific service or setting. Fix: verify the payer's coverage for new patient E/M.

Mistake: Using a new patient code when the patient was seen by another physician of the same specialty in the same group within three years. Fix: check the group's encounter history before selecting new vs established.

Mistake: Using an established patient code when the patient is new to the physician's specialty (different specialty in the same group). Fix: check the physician's specialty and the prior physician's specialty.

Mistake: Not counting non-face-to-face professional services (e.g., phone calls, portal messages billed as professional services) when determining new vs established. Fix: include all professional services within three years.

Mistake: Confusing the three-year clock (using the calendar year instead of the exact date three years prior). Fix: calculate the three-year window from the exact date of the last professional service.

Mistake: Using the wrong E/M code level for new patient E/M (higher or lower than warranted by MDM or time). Fix: use the MDM framework or time thresholds to select the correct code level.

Mistake: Not documenting the new vs established determination rationale, especially for specialty-specific encounters. Fix: document the specialty and the rationale for the determination.