How does CPT/E&M guidelines differentiate between a new patient and an established patient?

How does CPT/E&M guidelines differentiate between a new patient and an established patient?

• A. They use the same E/M code range
• B. New patient vs established status changes the applicable E/M code range and criteria
• C. New patients are not eligible for E/M services
• D. Established patients require no documentation

Answer: (B)

Understanding patient status matters because CPT/E&M distinguishes the work based on whether the patient is new to the physician or has an established relationship. This status determines the code range you can bill and the level of service criteria you must meet. A new patient visit uses codes in the new patient range, reflecting the greater history, examination, and medical decision-making required, while an established patient visit uses the established range with different thresholds for those components. The status is defined by whether the patient has received professional services from the same physician or from another physician in the same practice within the past three years. So the correct idea is that new patient versus established status changes both the applicable E/M code range and the criteria used to select the level of service. Statements that all patients share the same code range, that new patients can’t be billed for E/M, or that established patients require no documentation do not reflect how E/M coding is structured.

Understanding patient status matters because CPT/E&M distinguishes the work based on whether the patient is new to the physician or has an established relationship. This status determines the code range you can bill and the level of service criteria you must meet. A new patient visit uses codes in the new patient range, reflecting the greater history, examination, and medical decision-making required, while an established patient visit uses the established range with different thresholds for those components. The status is defined by whether the patient has received professional services from the same physician or from another physician in the same practice within the past three years. So the correct idea is that new patient versus established status changes both the applicable E/M code range and the criteria used to select the level of service. Statements that all patients share the same code range, that new patients can’t be billed for E/M, or that established patients require no documentation do not reflect how E/M coding is structured.