May 11, 2017

Question:
Our group has grown by merging or acquiring physicians from various different practices over the past few years. Can you provide some clarity about how we can determine whether the patients from these “new” doctors should be billed as new or established patients when they come to the “new” office?

Answer:
This is a great question and one that is really important with all of the mergers and acquisitions that are occurring with orthopaedic practices. The answer for this question actually starts in the December 1998 issue (p 9) of the CPT Assistant. This information was then updated in the CPT 2012 codebook’s Evaluation and Management Services guidelines. A question from 1998: Would it be appropriate to bill a patient as “new” if a physician changes practices and sees a patient that he or she had previously seen within the past 3 years while working for another medical group? The physician would not have access to the old medical records unless he or she requests them from the previous medical group. The American Medical Association (AMA) Commented:  The determining factor in assigning an evaluation and management (E/M) code for a new versus established patient is whether the patient received professional services from the physician within the past 3 years, regardless of the place of service. Thus, if the patient has received professional services from the same physician within the past 3 years, the patient is considered an established patient, even though the physician has changed medical groups. In CPT 2012, the above reporting instruction is unchanged, however it goes on to clarify:  In the previous scenario, the determining factor for choosing a new versus established patient E/M code is that physician services were previously provided by the same physician within the past three years, regardless of whether the physician changes practice settings. Similarly, if the patient is now seen for an E/M service by a new physician of the same specialty as the original physician in the former medical group practice, an appropriate level established patient office or other outpatient evaluation and management service code should be reported per the guidelines.

*This response is based on the best information available as of 05/11/17.