Every few months, we get a run of calls asking about selecting new patient office visit codes. Often, someone at the practice reaches out when a new provider or subspecialist joins the group and requests an outside opinion. In this article, we layout the criteria from the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) for determining new or established status when submitting claims for office visits. In addition, we will examine a few common scenarios.

The Subspecialty Issue

To start, there is some conflict between the American Medical Association’s (AMA’s) definition of new patient and CPT’s and third-party payers,’ including CMS’s, definition. The AMA publishes the following definition that recognizes “subspecialty”¹:

A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

In contrast, CMS does not recognize subspecialties in their new and established patient definition published in the Evaluation and Management Services Guide²:
New Patient: A person who didn’t receive any professional services from the physician. [sic] NPP, or another physician of the same specialty who belongs to the same group practice within the previous 3 years.
Established Patient: A person who receives professional services from the physician, NPP, or another physician of the same specialty who belongs to the same group practice within the previous 3 years.

CGS, the Medicare administrative contractor (MAC) for Kentucky and Ohio, quotes the AMA followed by the CMS definition.³ Additionally, other MACs, such as Noridian⁴ and commercial payers like United Healthcare,⁵ do not recognize subspecialties either. 

Although the AMA acknowledges subspecialties, CPT, Medicare and other third-party payers do not.

It is important to understand how the payers define “new” and “established,” since it affects processing claims. Because the CMS definition mentions “same specialty,” providers often ask about the subspecialty services within ophthalmology, such as retina, glaucoma, or oculoplastics. While taxonomy codes for these specialties exist,^6,7 the claims processing system only recognizes the specialty designations “18” for ophthalmology and likewise “41” for optometry.⁸ Please notice that the definitions identify both the group and the individual provider.

Before determining new or established, both the group NPI and individual NPI must be considered.

Examples

• A new physician joins a practice to take over the practice of a retiring doctor. The retiring physician transfers patients to the new provider. The new provider wants to code the visits as “new” because they are new to her. Both doctors are ophthalmologists in the same group practice, resulting in an established visit. 
• A glaucoma specialist leaves the academic practice across town and joins a new practice. Many of his patients from the university travel to see him. The practice wants to code these patients as “new” to the practice. The patients are established since they have a relationship with the NPI of the glaucoma doctor from his previous practice.
• The practice in example B scheduled Dr. Glaucoma’s patient to see another provider in the new practice. The patient has not seen anyone in the practice yet, and Dr. Glaucoma saw the patient with a different group. This visit is “new” because there is no past relationship to this physician NPI or with the new group.
• An optometrist in the group sees a new patient and asks the patient to see an ophthalmologist in two weeks. The patient returns to the ophthalmologist who codes this as “new.” As two distinct specialties, this could be a “new” encounter. However, many practices try to show a unified group amongst their MDs and ODs, and generally treat visits such as these as established visits. The public relations challenges may outweigh the small difference in reimbursement.

CMS Offers Help

It is easy to confuse “new” and “established” designations. CMS recognizes this confusion, and through the Recovery Audit program, developed an automated review on this topic in 2017. That same review process continues today.⁹ When new providers join your group or mergers occur, before filing a wave of new patient claims, review the specialty designations, NPI relationships and, of course, the 3-year window.  OM

References

1. CPT Evaluation and Management (E/M) Code and Guideline Changes (effective January 1, 2023). https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Accessed September 5, 2024.
2. Centers for Medicare & Medicaid Services. Evaluation and Management Services Guide. MLN Booklet. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf. Accessed September 5, 2024.
3. CGS Medicare. New vs Established Patients. https://cgsmedicare.com/partb/pubs/news/2016/07/cope33404.html. Accessed September 5, 2024.
4. Noridian Medicare. New Patient vs Established Patient Visit. https://med.noridianmedicare.com/web/jeb/specialties/em/new-vs-established-patient. Accessed September 5, 2024.
5. United Health Care. New Patient Visit Policy, Professional. 2024R9024B. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-New-Patient-Visit-Policy.pdf. Accessed September 5, 2024.
6. CMS. Taxonomy. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Taxonomy. Accessed September 5, 2024.
7. American Academy of Ophthalmology. Subspecialty Taxonomy Codes. https://www.aao.org/medicare/cost-taxonomy. Accessed September 5, 2024.
8. CMS. Medicare Claims Processing Manual. Chapter 26 Completing the Processing Form CMS-1500 Data Set. MCPM 26§10.8.2 Physician Specialty Codes. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed September 5, 2024
9. Recovery Audit Contractor Topics. 0043-New patient visits: Incorrect Coding. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0043-New-Patient-Visits. Accessed September 5, 2024.

Kirk Mack, COMT, COE, CPC, CPMA, is a senior consultant at BSM Consulting and is based in Galveston, Texas. He has more than 30 years of experience in the ophthalmic industry.