Wiki New vs Established

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IzumiTM

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Good Morning!

I code for an allergist who has not seen a patient face-to-face in over 3 years. The patient, however, has come in for their allergy shots that have been administered by our nurses. No E/M visit during those times. The patient has an appointment to see our allergist this week. Would this be considered a new patient visit or an established visit? Thank you all in advance!
 
A new patient is one who has:
  • not received any professional services (Ex: those face-to-face services rendered by physicians and other qualified health care professionals who may report E&M 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.

If the patient was being seen for nurse only visits billed with a 99211 this would meet the basic requirement for an established patient. The nurse would have been a qualified health care processional who reported an E&M code for the services rendered.

However, if the injection visits were billed with the material injected and a 96372 only, then you would meet the requirement for a new visit.
 
Established

The definition of new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” So, it's not just E&M codes - it is any professional services. The allergy injections performed by the nurse and billed under the allergist would qualify as services, so this is established.
 
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