Originally published March 7, 2020. Office E/M rules changed in 2021 (code 99201 was deleted and levels are now chosen by medical decision-making or time). Payer rules change; confirm current CMS and payer requirements before billing.
New and established patient definitions apply to services from a physician or qualified healthcare professional of the same specialty and subspecialty in the same group practice.
A new patient is someone who has not received professional services from the practice in the past three years. If the patient has been seen in the practice by that specialty within three years, the visit must be billed as established. New patient visits have more extensive requirements than established patient visits.
The new vs. established distinction applies only in the office setting. Emergency department visits are not split this way, since taking a complete medical history is critical in an urgent setting.
New patient CPT codes
All three key components (history, exam and medical decision-making) must be met.
- 99201: problem-focused history and exam, straightforward decision-making, about 10 minutes
- 99202: expanded problem-focused history and exam, straightforward decision-making, about 20 minutes
- 99203: detailed history and exam, low-complexity decision-making, about 30 minutes
- 99204: comprehensive history and exam, moderate-complexity decision-making, about 45 minutes
- 99205: comprehensive history and exam, high-complexity decision-making, about 60 minutes
Established patient CPT codes
Two of the three key components must be met.
- 99211: history, exam and decision-making not required, about 5 minutes
- 99212: problem-focused history and exam, straightforward decision-making, about 10 minutes
- 99213: expanded problem-focused history and exam, low-complexity decision-making, about 15 minutes
- 99214: detailed history and exam, moderate-complexity decision-making, about 25 minutes
- 99215: comprehensive history and exam, high-complexity decision-making, about 40 minutes
Clarifications and exceptions
When a patient is referred for treatment recommendations, billing a consultation code instead of a new patient code may pay more, but not for Medicare. Medicare stopped recognizing consultation codes because of past misuse.
New and established patient codes are based on face-to-face services. If the practice previously provided only a non-face-to-face service, such as reading an x-ray, interpreting a lab or calling in a prescription, a new patient code is still acceptable.
Once a patient is established, they stay established for three years regardless of insurance. Changing insurance does not make a patient new again.
When a physician moves to another practice, patients who follow them are still established at the new practice if the physician billed face-to-face services for them in the past three years, whether or not the records were transferred.
Likewise, if another physician at the old practice takes over patients who stayed behind, established patient codes still apply, because the new physician is of the same specialty in the same practice that billed in the past three years.