In 2012, the American Medical Association (AMA) revised its definition of a “New Patient” in its Current Procedural Terminology (CPT®) book. However, CPT®’s definition of a new patient did not mean Medicare would necessarily follow suit. Indeed, this change did not have any impact on Medicare Part B claims. CPT® defines a new patient as:

“A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years”.  (Reference: 2013 CPT® Manual: Pages 4-5)

One of the key areas of debate is the word “sub-specialty”. Medicare does not acknowledge sub-specialty designations in their computer systems, making CPT®’s definition irrelevant. Therefore, the instruction given by Centers for Medicare and Medicaid Services (CMS) for billing new and established Evaluation and Management (E/M) codes has remained the same. According to Medicare, a “New Patient” means a patient who has not received any professional services (that is, E/M or other face-to-face services such as a surgical procedure) from a healthcare provider in the same group practice and the same specialty within the previous three years. How about other non-Medicare payors, would they follow the definition in the CPT® book? Most likely not. Other payors, generally, follow Medicare guidelines. Keep in mind that most payors now carry Medicare Advantage products in their portfolio and, hence, they have incorporated Medicare guidelines in their own policies. It is also important to note that even if providers bill established patients as new, Medicare and other payors have a look back period where they would retroactively recoup their money back or penalize providers. So, if providers are being reimbursed now, this does not mean it is proper. For Medicare services, the same specialty is determined by the physician’s or the practitioner’s primary specialty enrollment in Medicare. Recognized Medicare specialties can be found online at: https://www.practicons.com/wp-content/uploads/2022/01/taxonomy.pdf It is helpful to see what CMS has to say about the definition of a “new patient”. The following is an excerpt from CMS’s Q&A at CMS.gov:

What is the definition of “new patient” for billing evaluation and management (E/M) services? Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician’s or practitioner’s primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (https://www.practicons.com/wp-content/uploads/2022/01/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation. (FAQ1969)

Reference: The CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.7