Question: I have a situation where our nurse practitioner (NP) performed a new visit for inpatient palliative care while the patient was in the hospital in October 2024. The patient was admitted again in November 2024 and our NP saw the patient again at that time. The NP billed for a new patient visit. Our third-party billing vendor is stating the November visit should be billed as an established patient visit instead of a new patient visit. Also, the billing vendor is stating that if the same patient was seen by our NP as an outpatient palliative and is admitted to the hospital a month later, that hospital visit should be billed as an established visit. I thought the new visits depended on each hospital stay. Is that incorrect? Any help would be greatly appreciated.
RCI Forum Participant
Answer: If your NP provided care to a patient in the hospital in October 2024, and then later saw the same patient in a clinic to establish care within the same specialty and subspecialty, your third-party billing vendor is correct in stating that this cannot be billed as a new patient visit.
The CPT® guidelines say: “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services. 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.”
The CPT® guidelines state that if a provider has seen a patient within the past three years, then the patient would be considered “established” during any professional service rendered, and an inpatient visit is considered a professional service.
So, in your scenario, the October visit would be the only new patient visit, and anything after that would be considered an established patient visit. Keep in mind that hospital codes don’t distinguish between new and established patients, so this will only apply to CPT® codes related to office visits or E/M services.
Lindsey Bush, BA, MA, CPC, Development Editor, AAPC
