# New patient vs established patient



## drsnpatil (Feb 26, 2010)

A patient who was not having coverage from any insurance has taken medical service by a provider and paid in cash at that time. After few months, the same patient takes medical service by same provider but now patient is covered by some insurance. The provider will consider this patient as new or established on this visit? 
Any suggestions will be greatly appreciated.

Thanks.


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## Cyndi113 (Feb 26, 2010)

Patient would still be established. This is not an insurance rule - its a CPT rule. The patient could have 10 different insurances but would still be established.


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## drsnpatil (Apr 2, 2010)

Cyndi113 said:


> Patient would still be established. This is not an insurance rule - its a CPT rule. The patient could have 10 different insurances but would still be established.



Thanks Cyndi.


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## anisjm (Apr 4, 2010)

Would the patient still be considered estabilished if the old practice is dissolved and a new one created.

In other words - the practice is under the tax id of the hospital and the old tax id and any other payer numbers won't be used.


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## aguelfi (Apr 5, 2010)

If the patient was seen by that provider within the last 3 years, he is considered established.


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## RGALVEZ (Apr 5, 2010)

The "key" in determining NP vs Est Pt is NOT the tax ID but the physician. If the pt has been seen by the "*Physician"*in the past 3 yrs, then they are Established pts.


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## rachell1976 (May 26, 2010)

How about if there were two physicians, same specialty, in the Same building, sharing call with eachother, sharing the same chart,  but billing as SEPARATE practices and under different TIN's.

Are their patients "established" to eachother?

I work for a hospital based clinic that just hired on these two physicians from private practice. They are now both employeed physicians in the same practice with the same TIN.

They think that because before they were billing w/ different TIN and owned their own practices they could consider eachother's patients as "new" the first time they were seen.


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## rsjbic (Jun 10, 2010)

*Same Tax ID, group and speciality, different location*

I have the same question - 2 physicians, separate locations, same tax ID, same group, same specialty.  We billed as a new patient but patient was seen by another FP in the same GROUP not the same PRACTICE and the claim denied stating they are not new because they have seen another physician within the group within the last 3 years.....any comments?


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## RebeccaWoodward* (Jun 10, 2010)

Interpret the phrase “new patient” to mean a patient who has not received any professional services ( i.e., E/M service or other face-to-face service ) from the physician *or* physician group practice (same physician specialty) within the previous 3 years.

Your patient would be deemed established by CPT and Medicare guidelines...


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## coder04 (Apr 20, 2011)

*Emergency room - Clinic*

Critical Access Hospital with a provider based Rural Health Clinic.  If patient was seen in the ER and then seen two weeks later in our RHC does this still qualify as an established patient even though they were seen in the hospital and then the clinic? Patient has never been seen in the RHC.


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## RenaHall (Apr 21, 2011)

*New vs Established*

Another scenario that needs to be remembered:
Ima Payne sees Dr. A as a regular patient.  Ima hs numerous medical problems and when Dr. A goes for an extended vacation, he asks Dr. B (DIFFERENT PRACTICE) to take care of patients in his abscence.  Ima is referred to Dr. B when there is a problem that needs attention.  Dr. B should bill Ima's visit as an established patient since he is "on-call" for Dr. A.
Rena


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## lynmitch (Apr 21, 2011)

Our doctor sees patients in the hospital for stress echos and stress tests, does that make them established when they are seen in the office after the test?


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## FTessaBartels (Apr 26, 2011)

*Established, Established, Established*

Forget about WHERE.  Makes no difference where you have provided services in the past.

If a patient has received *ANY face-to-face *service from the *same provider -OR-* ANY *provider with the same specialty and same practice *within the *last three years*, that patient is now an *established* patient. 

This is really a pretty simple rule.

 F Tessa Bartels, CPC, CEMC


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