Understanding Patient Types for E/M Billing
Correctly identifying patient types and services supports evaluation and management (E/M) code selection and Medicare billing compliance.
New Patient
A new patient is an individual who has not received any professional services from the same physician, nonphysician practitioner (NPP) or a physician of the same specialty within the same group practice within the previous 3 years.
Established Patient
An established patient is an individual who has received care from the same physician, NPP or a physician of the same specialty within the same group practice within the previous 3 years.
Note: If a provider moves to a different group practice, the patient-provider relationship follows the provider. The 3-year timeframe still applies when determining whether the patient is new or established.
Facility-Based E/M Services
For facility settings, patient encounters are classified as initial or subsequent services.
Initial Service
The patient has not received professional services from the physician, NPP or another physician of the same specialty within the same group practice during the current stay.
Subsequent Service
The patient has received professional services during the current stay from the physician, NPP or another physician of the same specialty within the same group practice.
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