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New vs established E&M guideline for an incoming provider

Charlene Posted Fri 13th of September, 2019 14:30:49 PM
Hello, A new provider has joined our practice and is continuing to treat patients he treated when he worked with another company. It is my understanding his previously treated patients are established to him if the patient was seen within past 3 yrs (36 months). The provider is a new specialty to our practice so when he treats a patient that has been treated by group within past 3 yrs, the patient would be new to him. I've attempted to located CMS or Palmetto guideline, but cannot find. I would appreciate it if you could direct me to the guideline.
SuperCoder Answered Mon 16th of September, 2019 09:24:12 AM

Hi Charlene,

Thank you for the question.



When the provider is a new specialty to our practice and treats a patient that has been treated by group within past 3 years, we would consider the patient established.

CPT defines an established patient as one who has received professional (face-to-face) services from the 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 36 months (three years).


If the provider gives treatment to patient face-to-face within the three years (in any location), that patient is established (in all locations) for him. Change of location or group doesn’t matter. This includes patients who are first seen in the hospital. When arriving and seen in the office, they are also established patients.


Also, because the patient is considered established to your new physician, that patient is considered established to all the physicians in the practice who are of the same specialty and subspecialty.

Please also check below links:


Feel free to ask for any further query.

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