An established patient appointment is a formal classification used by healthcare providers for billing and scheduling purposes. This designation determines which standardized codes are used to submit a claim to an insurance company following a visit. The distinction between a new patient and an established patient is governed by specific rules set forth in medical coding guidelines, not the patient’s current complaint or the physical location of the visit. Understanding this difference is important because it dictates the required documentation, appointment length, and complexity of the service provided.
Defining the Criteria for Patient Status
The official criteria for defining a patient’s status rely on having received “professional services” within a specific timeframe. An individual is considered an established patient if they have received professional services from a physician or qualified healthcare professional within the past three years. This service must have been provided by someone of the exact same specialty and subspecialty within the same group practice.
A new patient is someone who has not met this specific criterion within the three-year window. If a patient’s last visit was three years and one month ago, they must be classified as a new patient. The professional service must be a face-to-face encounter, such as an evaluation and management visit or a surgical procedure.
A service like interpreting a diagnostic test without a face-to-face encounter does not qualify as a professional service. A patient who has only had a diagnostic test interpreted remains a new patient for their first in-person consultation. If a patient sees providers in different specialties (e.g., a cardiologist and a gastroenterologist) within the same large medical group, they are considered a new patient for the second specialty.
The Purpose Behind Patient Classification
Healthcare systems maintain the distinction between new and established patients because it is tied to standardized Current Procedural Terminology (CPT) codes used for billing. These codes are grouped into separate ranges depending on patient status. Established patient office visits use CPT codes 99211 through 99215, while new patient visits use codes 99202 through 99205.
The different code ranges acknowledge the administrative and clinical work required for each visit type. New patient visits require greater initial work to gather a complete medical history, which is unnecessary for someone whose record is already on file. The coding system reflects this difference in effort and resource allocation.
The classification also dictates the required level of documentation a provider must record. New patient codes necessitate a more comprehensive record of history, a detailed physical examination, and a higher threshold for medical decision-making complexity. This robust initial documentation establishes a baseline for the patient’s ongoing care and supports the complexity of the visit for insurance claim submission.
This classification aids in managing a practice’s schedule and provider resources. New patient appointments require a longer dedicated time slot to accommodate the comprehensive evaluation and data gathering. Accurately classifying patients allows a medical office to allocate appropriate time and personnel, preventing delays.
Practical Differences in Established vs. New Appointments
Patients experience tangible differences when scheduling and attending established appointments compared to new patient visits. The most noticeable difference is the scheduled duration. Established patient appointments are generally shorter, focusing on a specific follow-up, routine check-up, or a single acute complaint.
A new patient visit is scheduled for a significantly longer period to allow for the comprehensive intake process. This extended time is needed for the provider to conduct a full review of systems, understand the patient’s complete medical history, and establish a foundational relationship. For example, an established visit coded at moderate complexity might take 30 minutes, while a new patient visit at the same complexity requires more time.
The amount of paperwork involved also differs considerably. New patients must complete extensive registration packets, including detailed medical history questionnaires, privacy notices, and consent forms. Established patients typically only need to verify that their personal information, insurance details, and current medication list are up-to-date, making the intake process quicker.
While the patient’s copayment or deductible application might be the same, the underlying charge submitted to the insurer can vary. New patient visits correspond to codes that have a higher Relative Value Unit (RVU) than established patient codes at a similar complexity level, reflecting the greater initial work. This means the underlying charge for a new patient visit is frequently higher, which can affect how much is applied toward a patient’s deductible, although the final out-of-pocket cost is highly dependent on the individual’s insurance plan.