You're correct. Per
CMS E/M guidelines on page 4 (usually always helpful when you can direct people to official references):
PATIENT TYPE
For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.
New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty
who belongs to the same group practice within the previous 3 years.
Established Patient: An individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years.
My local MAC (
Noridian):
New Patient
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.
For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation.
Established Patient
Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.
Clear and concise medical record documentation is critical to providing the patients with quality care. When billing for a patient's visit, select the level of E/M that best represents the service(s) provided during the visit. Services must meet specific medical necessity requirements and the level of E/M performed, based on the CMS 1995 This link will take you to an external website. or 1997 This link will take you to an external website. Documentation Guidelines for E/M Services.
The rationale for new versus established patient is based on the provider's National Provider Identifier (NPI).
If Noridian is not your local MAC, it might be worthwhile locating them and they will most likely have an educational page to show your practice manager/providers.
Hope these references are helpful!