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Psychiatry Coding & Reimbursement Alert

Reader Question:

Consider These Factors to Decide if Patient is New or Established

Question: We had a patient who was referred to us by another doctor for some psychological tests. Our psychiatrist was not present for the test, and a technician performed the test. Should I consider this patient an established patient?

Texas Subscriber

Answer: No, you should consider the patient “new” until a face-to-face encounter with your psychiatrist (or another psychiatrist in the same group practice) occurs.

According to AMA CPT® guidelines, a new patient is “one who has not received any professional 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.” For purposes of this definition, professional services are “face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT® code(s).” Thus, if the primary physician (or another physician of the same specialty billing under the same group number) provided a non- face-to-face service for a patient and then provided a face-to-face service within three years, you should still consider the patient to be “new” when selecting an E/M service code.

The 3-year rule is a well-established rule for “new” versus “established patients. That is, if any physician of a given specialty within a given practice sees a patient within a 36-month period, that patient is considered “established” for that physician and all other physicians of the same specialty in the same practice. If visits occur outside of that time period, the patient would return to new patient status.

As noted, if two specialists are of the same specialty and billing under the same group number, the three-year rule applies. If they work under different specialties or bill under different provider numbers (and thus are not considered part of the same group practice), the second specialist may be able to report the patient as “new,” as long as he hadn’t seen that patient within the previous 36 months.