Determining whether a patient is new or established shouldn’t be complicated — but coding CPT 99201-99215 office visits is oftentimes not so clear. Miscoding these E/M visits, however, can cost you thousands of dollars each year in lost revenue.

In fact, selecting an established patient when you should have billed a new patient office visit can cost you $64 per visit. But help is at hand. Check your skills with the following foundations and quiz on commonly miscoded scenarios.

Adhere to CPT 99201 – 99205 vs 99211 – 99215 Office Visit Requirements

So what’s the difference between a new or established patient? According to 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.
• An established patient is one who has received 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.

Whether you’re coding for a new or an established patient, there are three core parts, or criteria, to the code. Within each part, there are varying degrees of complexity which you will assign to your patient. These include:

• History and Examination – Problem focused, expanded problem focused, detailed, or comprehensive
• Medical Decision Making (MDM) – Straightforward, low, moderate, or high
• Presenting Problem (Severity) – Minimal, self-limited or minor, low to moderate, or moderate to high

Physicians should follow E/M documentation for use of CPT 99201-99215 office visit codes, based on visit complexity and whether patient is a new or established patient. For a new patient, you have to meet all 3 criteria, but for an established patient you only need two.

New Patient CPT Codes 99201 – 99205:

• 99201 – Problem focused, straightforward MDM, minimal severity, average 10 minute face-to-face visit
• 99202 – Expanded problem focused, straightforward MDM, self-limited or minor severity, average 20 minute face-to-face visit
• 99203 – Detailed, low MDM, low to moderate severity, average 30 minute face-to-face visit
• 99204 – Comprehensive, moderate MDM, moderate to high severity, average 45 minute face-to-face visit
• 99205 – Comprehensive, high MDM, moderate to high severity, average 60 minute face-to-face visit

Established Patient CPT codes 99211 – 99215:

• 99211 – Minimal severity, average 5 minute face-to-face visit
• 99212 – Problem focused, straightforward MDM, self-limited or minor severity, average 10 minute face-to-face visit
• 99213 – Expanded problem focused, low MDM, low to moderate severity, average 15 minute face-to-face visit
• 99214 – Detailed, moderate MDM, moderate to high severity, average 25 minute face-to-face visit
• 99215 – Comprehensive, high MDM, moderate to high severity, average 40 minute face-to-face visit

Note: Face-to-face time refers solely to the time spent with the physician, not other support staff.

Test Your Skills With 3 CPT 99201 – 99215 Office Visits Tricky Scenarios

Even knowing the codes and levels of severity, deciding when to bill for a new or established patient visit is tricky because of the different variables. Use these 3 scenarios to quiz yourself and spot clues to help you recall and properly code your patient CPT 99201-992015 office visits:

Scenario #1: A patient receives a facial in the ENT medical spa and then makes an appointment to see the ENT. Is the ENT visit billed as a new or established patient visit?

Answer: New, because for the visit to be classified as an established patient, the code must be billed using a CPT code.

Scenario #2: A pediatrician sees a patient, suspects ADHD, and refers the patient to a developmental pediatric specialist within the same practice with the same Tax ID number. Is the patient’s visit with the developmental pediatric specialist billed as a new or established patient encounter?

Answer: New, provided the specialist is recognized as a unique specialty and patients are referred for specialty areas that specialist handles.

Caveat: There are many specialties that can practice under the same Tax ID and be counted as different specialties, so you have to check how you are filed. For example, a patient who gets an in office referral to an ophthalmologist from an Optometrist might be considered an established patient.

Scenario #3: A physician provided an E/M service for a patient who was seen a year ago in the same office by a physician of the same specialty but different subspecialty. Will the health insurance company reimburse a New Patient E/M code if reported in this situation?

Answer: No, not if they are following CMS policy. Under CMS policy, they will reimburse a New Patient E/M code if the patient has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. In this case the patient was seen only one year ago. Prepare for Massive 2021 CPT 99201-99215 Changes While you don’t have to worry about any E/M changes in 2020, effective January 1, 2021, CMS is implementing a few significant E/M code changes for CPT 99201-99215 office visit codes, including:

• 99201 will be deleted
• More flexibility to document new or established visits based on the current method, time, or medical decision making
• New term clarifications and definitions for MDM
• Changes in how time is calculated, including a new time range for visits and non-face-to-face time spent that same day

It’s important to know the distinction between new and established patients now and get it right before CPT E/M 2021 changes take place. You need strategies to help, such as tips on how to utilize the CPT decision tree to accurately determine a new vs established patient, and how to ensure your records are audit-proof to justify new and higher-level visits.

For all this and more, including how to cut down on your E/M denials and receive higher reimbursements for your office visits, sign up for national coding expert, Kim Garner Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO’s 60-minute online workshop today!

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