BCBSRI follows the American Medical Association (AMA) Current Procedural Terminology (CPT) guidelines on new and established Patients. By CPT definition, a new patient is “one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." By contrast, an established patient has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.

Examples of an established patient

Practice location change

A cardiologist leaves one group practice and joins another cardiology group practice. Some of the patients transfer their care to the new practice. One of the patients who transferred was established to the cardiologist presents to the new practice and sees one of the cardiologists. The patient is considered established to all the physicians in the new practice who are of the same specialty and subspecialty. A change in tax id or physical location doesn’t change that the patient is established.

Covering or on-call physician

A pediatrician is out of town for a few days and there is a coverage arrangement with another pediatrician in a different practice. An established patient is seen by the covering pediatrician at his/her practice location. The patient is considered established to the covering pediatrician. The encounter is based on the patient’s status with the unavailable physician. So if the patient is established to them, the patient is established to the covering physician.

Prior face-to-face encounter

A colorectal surgeon provides inpatient hospital care for a patient. Prior to the hospitalization, the patient has never seen the colorectal surgeon. The patient is discharged home and fails to follow up as requested. One year later the patient calls the office of the colorectal surgeon seen in the hospital requesting to establish care. The patient is considered an established patient, regardless of which physician in the group practice of the exact same specialty and subspecialty provides care. The location of service will not change that a prior professional encounter occurred within three years.

Nurse practitioner/Physician assistant encounter

A patient presents to a dermatologist office. The visit prior was performed by the nurse practitioner two years ago. The patient is considered an established patient. CPT definition bundles the physician with a qualified health care professional in their definition of new vs. established patients. Qualified non-physician practitioners are considered part of the group practice and specialty for which they provide service along with physicians in the same specialty and group practice.

Urgent Care Visit

A patient presents to a local urgent care for a cough then six months later presents to the same urgent care for lower back pain. The patient is considered established. It is a common misconception that all urgent care patients are new patients and can therefore always be billed as new. Urgent care centers are subject to the same guidelines for new vs. established patients as every other practice.

Examples of when a patient is considered a new patient

No prior face-to-face encounter

A patient is referred by their primary care provider to a cardiologist for chest pain. The cardiologist is asked to review and read an EKG test prior to the initial visit. The patient represents for the initial visit. The patient is considered new for the initial visit since no face-to-face encounter with the patient was performed. An interpretation/reading of a diagnostic in the absence of an E/M service or another face-to-face encounter with the patient doesn’t count as professional service.

Prior face-to-face encounter over three years ago

A patient returns to see their allergist. The last office visit was a little over three years ago. A year ago the patient called for a refill on their allergy medication. The patient is considered new. Calling in a prescription does not define a professional service and the last face-to-face encounter was over three years ago.

Same practice, different specialty

A patient regularly sees the pediatrician in the group. The patient is now 18 years old and transfers care to a family medicine physician in the same group. The patient is considered new to the family physician. The specialties of the physicians are different.

Please note examples provided are not all-inclusive and are not intended to take the place of AMA or CMS guidelines.