Primary Care Coding Alert

Question: If one of our FPs referred a patient to one of our NPs for primary care, will the patient be considered new, as he is seeing the NP for the first time, or established, as he has already been seen by our FP?

Missouri Subscriber

Answer: As per CPT®, “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” Otherwise, the patient is considered “established.”

So, you can only bill the patient as a “new patient” if the patient is being seen by your NP for the first time and no other physician or qualified health care professional of the exact same specialty and subspecialty in your practice has seen the patient in the past three years. If the NP’s specialty is family medicine, then in the case scenario that you have described, the patient should probably be considered “established,” because he has already visited your FP and been referred to your NP for other services. That is, if your FP and NP are considered the exact same specialty and subspecialty, you cannot report the patient as a “new patient” even though he is seeing your NP for the first time.

Note that even in situations where it is technically acceptable to report the patient as “new” (e.g. the NP’s specialty is different from that of the FP in the group), you may still want to report the patient as “established,” because the patient may not understand the distinction and consider himself established to the practice, given his relationship with the FP. In other words, patient relations may trump correct coding, especially if the patient has to pay more for a “new patient” visit.