Primary Care Coding Alert

Question: For physicians in a federally qualified health center (FQHC), are there different new/established patient rules?

Indiana Subscriber

Answer: No, there is no difference between FQHC's and office visit new or established patient guidelines. Both settings follow the AMA's three-year rule based on the provider specialty type as dictated by CMS guidelines.

Remember the three-year rule. You should consider a patient to be established if any physician in your group practice of the same specialty billing under the same group number has seen that patient for a face-to- face service within the past three years.

Quick tip: The CPT manual also discusses this thoroughly in the first part of the book under the Evaluation and Management (E/M) Services Guidelines. It even has a decision tree to help you determine whether a patient should be considered new or established.