New v Established - What is the difference?

Author: Tom Freedland, DC
TFreedland@aol.com 


This issue comes up quite frequently with personal injury patients.  
The CPT code book defines a new patient as someone who has never 
been seen in your office before or has not been seen in the last three 
years.  There is no distinction for a new injury. By definition, if 
you've seen this patient for any reason within the preceding three 
years it is inappropriate to bill your evaluation with this individual 
as a new patient exam.  There are some exceptions, usually for 
individual state Worker's Compensation programs.  When you think 
about the logic of the situation, it does make sense. If you've seen 
this person on a prior occasion, you already have some current, 
pertinent past history, and the level of evaluation that has to be 
performed is decidedly less, or should be if you have been providing 
an adequate history and ongoing chart record.  

Now, before some of you start screaming about the work involved in 
that initial examination, understand something else.  For an 
established patient CPT code you only have to meet two out of the 
three main criteria:  History, Examination, and Clinical decision-
making process.  So the level of your clinical documentation does not 
need to meet the same standard as for a new patient code of a 
similar level of service.

When you use an established patient code for a patient who develops 
a new injury, such as soft tissue trauma from a motor vehicle 
accident, make sure you explain what you have treated the patient 
for in the past, when they were last seen, and what their condition 
was the last time you saw them.  This does several things.  First, it 
helps the insurance company or insurance reviewer have a better 
understanding of the patient's baseline at the time of the accident.  
It also helps clarify the use of the established patient code, and in 
the process it builds credibility for the provider.  Don't use, "Past 
medical history is non-contributory" without further explanation as 
it can create a question of doubt.  Is the provider trying to hide 
something?  A brief sentence or two to explain why the prior 
condition may be unrelated would help to avoid any confusion.  If the 
person had a lifting injury and hurt their low back, but previously 
treated for a neck problem, that clarification he!
lps establish that the patient had no related pre-existing condition.  
Besides, with most of the evaluation and management codes the 
history portion should include information about past medical 
conditions because that's part of the definition!  

Conversely, the doctor's credibility in understanding CPT coding will 
come into question if a new patient code is used for an established 
patient that is later shown to have been previously treated by the 
doctor.  Such information also brings into doubt the accuracy of any 
recorded history about the patient's condition.  

I've heard doctors argue that if they are treating somebody from a 
motor vehicle accident it should be "their right" to bill with a new 
patient evaluation and management codes.  Unfortunately, that is not 
how the codes are defined, and there is no distinction or exemption 
from the definitions based on a doctor¼s degree.  These codes have 
specific definitions, and they apply to all providers acting within 
their scope.  If you don't like the definition, work with your various 
representative organizations to try and change them.  But until such 
time as the definitions are changed, arguing an individual right to 
use a code makes about as much sense as insisting that 2+2=5 or 
that the color of grass is pink.