The term “established patient” is a technical administrative designation used in healthcare primarily for accurate billing and documentation. This status is determined by strict, time-based rules set by medical coding guidelines, specifically the Current Procedural Terminology (CPT) published by the American Medical Association (AMA). The designation is applied to a patient’s medical record to determine the appropriate service codes for an Evaluation and Management (E/M) visit. Incorrectly classifying a patient as new or established can lead to claim denials, payment delays, and potential auditing issues for the provider.
The Core Definition and Criteria
An established patient is defined as one who has received professional services from a physician or another qualified healthcare professional (QHCP) of the exact same specialty and subspecialty within the same group practice within the preceding three years. This definition is based on CPT guidelines used by medical coders and insurance payers. The professional service must have been a face-to-face encounter; an interpretation of a diagnostic test, such as an X-ray or EKG, without a direct encounter does not count toward establishing this status.
The three-year look-back period is a strict requirement; if the last professional service occurred three years and one day ago, the patient is considered new for billing purposes. The “same group practice” is generally determined by the organization’s shared tax identification number (TIN). A patient is established to the entire group of providers of the same specialty who bill under that single TIN.
A patient who sees a provider in a different specialty within the same large hospital system may still be considered a new patient for that second provider. For instance, a patient established with a family medicine physician is considered new when visiting a cardiologist in the same clinic, as the specialties are different. The status is tied to the combination of the group practice, the specific specialty, and the three-year window.
Defining the “New Patient” Counterpart
A patient is classified as new if they have never received professional services from the physician or another QHCP in that same specialty and group practice. This status also applies if the last face-to-face encounter occurred more than three years prior to the current visit.
The patient’s personal history or feeling of familiarity with the clinic is irrelevant to this administrative designation. For example, a patient seen by a doctor in the group’s orthopedic department two years ago is classified as a new patient when visiting the group’s neurology department. The status is determined strictly by the specific specialty and group relationship.
If a provider recently joined a new practice, the patient is considered established if the provider’s former practice was part of the same group structure. Conversely, if a provider joins a new, separate group, a patient who follows them is considered a new patient to the new practice, unless they were already established with another provider in that new group’s same specialty. The “new” status is about the administrative entity providing the care, not the patient’s first time meeting the individual provider.
Administrative and Financial Implications of Status
The distinction between new and established patients is directly linked to documentation complexity and provider compensation. Different Current Procedural Terminology (CPT) codes are used for each status, signaling the service provided to the insurance payer. New patient office visits are billed using codes in the CPT range of 99202–99205, while established patient visits use the codes 99212–99215.
This coding separation exists because new patient visits generally require significantly more work from the provider. The provider must establish a complete medical history, perform a comprehensive initial examination, and develop an initial treatment plan, requiring more time and extensive documentation. For example, a new patient visit of moderate complexity (CPT 99204) typically requires 45 to 59 minutes of total time, compared to an established patient visit of similar complexity (CPT 99214), which usually takes 30 to 39 minutes.
Due to increased time and documentation, new patient visits are assigned higher relative values and receive higher reimbursement rates from insurance companies. This higher compensation reflects the additional resources expended by the practice to establish a patient’s baseline health information. For the patient, this often translates into higher out-of-pocket costs, such as a larger copayment or coinsurance, compared to a routine established patient follow-up.
Established patient visits focus on follow-up care, monitoring a chronic condition, or adjusting an existing treatment plan. Since the provider already has the patient’s history and baseline data, the encounter is typically shorter and the documentation is less comprehensive. Using the correct new or established patient code is a fundamental requirement for accurate medical billing and compliance with payer rules.