New Patient & Established Patient Codes

New Patient - A new patient is one who visits to take a service for the first time or one who 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.

Established Patient - An established patient is one who has received professional services from a physician or another physician in the same group and the same specialty within the past three years.

New Patient Codes - 99202, 99203, 99204, 99205

Established Patient Codes - 99211, 99212, 99213, 99214, 99215

On Call Scenario:

               Claim denied as New patient/Established patient criteria not met

                                                        ↓

                                       May I get the denial date?

                                                        ↓

                                     Check the billed CPT code

                                          ↙                            ↘

                                       ↙                                  ↘

                New Patient CPT Codes             Established Patient CPT Codes

                     (99202, 99203,                        (99211, 99212, 99213

                      99204, 99205)                              99214, 99215)

                               ↓                                                    ↓

             Check in system if any of               Check in system if any of

         these 9 codes have been billed    these 9 codes have been billed

               previously in last 3 years              previously in last 3 years

                   ↙                              ↘                  ↙                        ↘

                ↙                                    ↘            ↙                              ↘

              No                                     Yes     No                              Yes

               ↓                                           ↘ ↙                                     ↓

 We have not billed any                 May I have the         We have already billed

  new or established                   claim# & call ref#?     new or established CPT

patient CPT in the last 3                                              in the last 3 years. Can

 years. Can you please                                               you please reprocess the

 reprocess the claim as                                                 claim as it was denied

it was denied incorrectly?                                                     incorrectly?

               ↓                                                                               ↓

    What is the TAT                                                           What is the TAT

   for reprocessing?                                                         for reprocessing?

               ↓                                                                                ↓

 May I have the claim#                                                  May I have the claim#

        & call ref#?                                                                 & call ref#?

Important Note:

When working on these E/M codes, you will come across 2 scenarios,

1) Billed CPT is a new patient code and the claim denied as billed CPT is invalid as a patient is already an established patient:

• In this scenario, always check the patient's historical DOS in the software to find out if a patient has already taken service in the past 3 years from the billed date of service. 

• If not then make a call to insurance to confirm it from the insurance rep. Sometimes, a patient has taken the services in the past 3 years but that information is not available in the software. 

• If the insurance rep confirms that the patient has already taken service in the past 3 years then ask for the date of service and make a note of the same then assign it to the coding team to code the correct CPT. 

• If the insurance rep is unable to find any service in the past 3 years then ask the rep to send the claim back for reprocessing.

2) Billed CPT is established patient code and claim denied as billed CPT is invalid as a patient is a new patient:

• In this scenario, always check the patient's historical DOS in the software to find out if a patient has already taken service in the past 3 years from the billed date of service.

• If yes then make a call to insurance and ask the rep to send the claim back for reprocessing.

• If not then assign to the coding team to code the correct CPT.

If you are not a certified coder then do not try to change the CPT until you do not have any specific client updates. Coding a correct E/M code is based on various factors such as history, exam, and time. So, always get a confirmation from the coding team.

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Select Billed CPT:

* New Patient CPTs Existing Patient CPTs

Are any new patient or existing patient cpts billed in the last 3 years?:

* Yes No

What type of CPT billed previously?:

* New Patient CPTs Existing Patient CPTs

TAT for Reprocessing:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Adjust off the claim Appeal Sent Need client assistance Need coding assistance Need to allow time Need to send an appeal Resubmitted the claim Updated correct CPT and resubmitted the claim



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