The administrative process of classifying a patient as either “New” or “Established” is necessary for accurate medical billing and shapes the documentation required for the appointment. Understanding this classification directly impacts the patient experience, including the length of the visit, the depth of the initial assessment, and ultimately, the cost of the service.
Defining Patient Status
The distinction between a new and an established patient is an administrative one, not a clinical judgment of familiarity. A patient is classified as “New” if they have not received any professional services from the physician or another physician of the exact same specialty and subspecialty within the same group practice. This definition ensures that the healthcare provider is compensated for the additional effort required to gather a complete medical history.
Conversely, an “Established Patient” is someone who has received a professional service from a provider or another qualified healthcare professional within the same group practice and specialty during the relevant time period. The status is tied to the specific physician or a colleague of the same specialty in the same practice, not just the patient’s memory of their last appointment. This classification simplifies follow-up care by recognizing that the provider or group already possesses a medical record for the individual.
The Standard Time Frame for Classification
The time frame used to determine a patient’s status is set by the Current Procedural Terminology (CPT) guidelines, which are adopted by Medicare and nearly all commercial health insurers. A patient is considered new again once 36 months have passed since their last professional service with the provider or the group. Once this 36-month period expires, the patient’s record effectively resets for billing purposes.
The clock is reset by the delivery of a professional service, which CPT guidelines define as a face-to-face service rendered by a physician or other qualified healthcare professional. This generally includes in-person office visits or qualifying telehealth appointments. Crucially, a physician merely interpreting a diagnostic test without a direct patient encounter does not constitute a professional service and will not restart the three-year clock. If the patient returns one day after the 36-month mark, they will be classified as new, triggering the requirements for a comprehensive initial visit.
Why Patient Status Affects Billing and Visit Complexity
The patient’s classification directly influences the complexity level of the Evaluation and Management (E/M) service and the corresponding CPT code used for billing. New patient visits require a more comprehensive assessment, including a full history, a detailed physical examination, and complex medical decision-making. These requirements are reflected in the specific range of CPT codes used for new patients, such as the 99202 through 99205 series.
The higher-level codes assigned to new patient visits reflect the increased work and time required to establish a comprehensive baseline of care. This distinction results in a higher reimbursement rate from the insurer and consequently, a higher charge to the patient compared to an established patient visit of the same complexity. Established patient visits, which use the 99211 through 99215 code series, often require documentation of only two of the three key components, allowing for more focused follow-up care. The additional documentation and time needed for a new patient often necessitate a longer appointment slot.
Rules for Group Practices and Different Specialties
The definition of a group practice centers on a single entity that operates under one Tax Identification Number (TIN). This structure means that a patient is considered established to the entire group, provided the other providers are of the same specialty and subspecialty. If a patient sees a different physician within the group, but both are, for example, cardiologists, the patient remains established as long as it is within the three-year window.
However, the patient can be designated as new if they switch to a provider of a different specialty within the same multi-specialty group. For instance, if a patient is established with a cardiologist in a large clinic and then makes an appointment with a dermatologist in the same clinic, the visit to the dermatologist will be billed as a new patient encounter. The specialty designation is the determining factor, ensuring that the new specialist is compensated for performing a comprehensive, specialty-specific initial assessment.