How Often Can You Bill a New Patient Office Visit?

Properly classifying patient visits for billing purposes is fundamental in healthcare operations. Accurate billing practices are essential for compliance with regulatory standards and securing appropriate reimbursement. Understanding patient status ensures adherence to established guidelines, supporting financial stability. This foundational knowledge helps prevent billing errors that could lead to claim denials or audits.

Defining Patient Status

Distinguishing between a “new patient” and an “established patient” is a core concept in medical billing, governed by Current Procedural Terminology (CPT) guidelines. A “new patient” is defined as an individual who has not received any professional services from the physician or another physician of the same specialty within the same group practice within the past three years. This look-back period determines the appropriate billing category for a patient encounter.

Conversely, an “established patient” is someone who has received professional services from the physician or another physician of the same specialty within the same group practice within the three-year timeframe. The concept of “same group practice” is identified by a shared Tax Identification Number (TIN). All providers billing under the same TIN are considered part of the same group. If a patient sees different providers within the same group, their status as new or established depends on the specialty of the treating physician and the look-back period.

The definition of “same specialty” is also important, as providers within the same group practice but different specialties are treated distinctly. For instance, a patient seeing a cardiologist in a multi-specialty group would be considered a new patient if they had previously only seen a gastroenterologist within the same group. This distinction ensures accurate claim submission and helps avoid billing discrepancies.

Timeframes and Scenarios for New Patient Billing

The “three-year rule” serves as the primary benchmark for determining when a patient can be billed as new again. If an individual has not received any professional services from any provider of the same specialty within the same group practice for more than three years, they are once again classified as a new patient. This allows for a new patient office visit code to be submitted. For example, if a patient last saw an internal medicine physician in a group practice four years ago, and now returns to see any internal medicine physician within that same group, they would be considered a new patient.

Several scenarios permit billing a patient as new, even if they have a history with the group practice. A patient who receives services from a provider in the same group but a different specialty is considered a new patient for that specific specialty. This applies even if they were recently seen by another provider within the same group for a different medical issue.

Another common situation involves a patient being seen by a new provider who has recently joined an existing group practice. If the patient has not received professional services from any provider in that specific specialty within the group for the three-year period, they can be billed as a new patient to the group, regardless of previous encounters with other specialties in that group. It is important to note that these rules apply specifically to professional services, which involve direct patient care and medical decision-making. Administrative interactions or technical services, such as laboratory tests or imaging, do not typically count as professional services for the purpose of determining new versus established patient status.

Billing Codes and Documentation Requirements

Accurate billing for new patient office visits relies on the appropriate selection of Current Procedural Terminology (CPT) codes. New patient office visits use CPT codes 99202 through 99205, which reflect varying levels of complexity in history, examination, and medical decision-making. In contrast, established patient office visits are billed using CPT codes 99212 through 99215, indicating a less extensive evaluation for patients with an existing relationship with the practice. The choice between a new patient code and an established patient code depends on the patient’s status as defined by the three-year rule and specialty criteria.

Medical record documentation is important to support the chosen CPT code and the classification of the patient as “new” or “established.” The medical record must clearly justify the level of service billed, detailing elements such as the patient’s chief complaint, a history of present illness, review of systems, and past medical, family, and social history. The physical examination findings and the complexity of the medical decision-making involved in the encounter are also important components.

Documentation should also reflect the time spent with the patient, especially if time is used for code selection. This includes face-to-face time with the patient and family, as well as non-face-to-face time spent preparing for the visit or documenting after it. Maintaining records that demonstrate compliance with these requirements is essential for proper reimbursement and serves as a safeguard during potential audits. The integrity of the medical record directly supports the financial claims submitted.