Orthopedic Coding Alert

Answer the new-vs.-established question correctly every time

Take the AMA's advice and answer these five questions to determine definitively if you should treat a patient as -new- or -established- for coding purposes.

1. Has the patient ever received any professional services from any physician in this group?

No: The patient is New.     Yes: Go on to question 2.

2. Has the patient received any professional service from a particular physician within the past three years, who is now reporting service?

Yes: The patient is Established.    No: Go on to question 3.

3. Has the patient received any professional service* from a physician in the group of the same specialty, within the past three years? (*CPT defines a professional service as -those face-to-face services rendered by a physician and reported by a specific CPT code.-)

No: The patient is New.     Yes: Go on to question 4.

4. Has the patient received care from a physician of the exact same specialty within the past three years, or is a physician of a different subspecialty now providing care?

The providing physician is of the same specialty:  The patient is established. 

The providing physician is of a different subspecialty: Go to question 5.

5. Does the current providing physician have the same tax ID as the physician who provided a separate service within the past 36 months?

Yes: The patient is Established.     No: The patient is New.

Editor's note: You can also find a similar flowchart on page 2 of the -Evaluation and Management (E/M) Services Guidelines- portion of CPT 2007: Professional Edition, published by the AMA.