What is a new patient? The question sound simple but it is not. The CPT defines a new patient as a patient who has not received any professional service from the physician or another physician in the group of the same specialty within the last three years. Every part of the sentence is important.
A professional service is an evaluation from a physician. It does not matter where the evaluation was performed. If you see a patient in the Emergency Room or in the hospital, and then the patient comes to the office and sees you there that patient is established. This means, even though the patient is new to your office location, he or she is not a new patient.
Tip 1.
It is important to have your consultation notes and ER evaluation notes in your office electronic medical record, so you have documentation that the patient was seen by you. The insurance company knows if the patient is established when you bill because your National Provider Identification number is listed on the claim. This situation can become even more complicated when you moonlight or work in more than one practice. One practice (meaning a group with a different Tax ID) does not know you may have seen that patient at an urgent care center (a group with a different Tax ID). This is often discovered when the claim is rejected.
Unless you are in a solo practice, you have joined a group of physicians. As a pediatrician you are a member of a group of other pediatricians. As an ophthalmologist you may be in a group of other ophthalmologists. If one of your pediatrician or ophthalmology group members sees a patient in the emergency room or in the hospital, and then that same patient tries to establish care with you, the patient is not considered a new patient. I have two new ophthalmology partners in my group. They practice in a different office location, but they have the same TAX ID. I have so we are considered a group. If they see patient that I have seen within the past 3 years, they have to bill the patient as established because we are in the same group. If I see a patient that they have seen before I have to bill them as established because we are of the same specialty and the same Tax ID.
Tip 2.
If there are multiple physicians in your group, always have you staff check to see if the patient has a chart.
A new patient cannot see a physician of the same specialty in the past 3 years to be considered new. There are many multispecialty groups in medicine today. If a patient who sees the internal medicine physician goes to see the cardiologist in the same group, the patient is new to the cardiologist. These physicians are not of the same specialty.
The good news is that if you have seen a patient previously in your practice, and the patient was evaluated over 3 years ago, you can bill the patient as new.
In summary, if you are a physician new to practice and you join a group, make sure that patient has not seen a physician with the same specialty as you, so you can bill them as a new patient. If you are a physician that has left a group and your patient from your previous practice follows you to your new practice, they are established even though your practice is new.