If a non-physician practitioner (NPP)—but not a physician—has seen a patient within the last three years, is the patient new or established?
Although CPT® consistently uses the term “physician” in the context of determining whether a patient should be considered “new” or “established,” most payers—Medicare payers in particular—don’t apply that instruction literally. For example, Medicare’s definition of a new patient, taken from the Medicare Carriers Manual, instructs:
“Interpret the phrase ‘new patient’ to mean a patient who has not received any professional services, i.e., E/M 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” [emphasis added.]
Because the NPP would be a member of the group practice, if he or she has seen a patient within the past three years, that patient would be established with the group.
The Centers for Medicare & Medicaid Services (CMS) offers even more explicit instructions in its MLN Evaluation and Management Services Guide:
“For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.
“A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.
“An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years” [emphasis added].
The bottom line: If the patient has seen an NPP in the practice within the previous three years, you should treat the patient as established.
But remember, a patient is established only if the physician or NPP provides a face-to-face service within the past three years.
“For example,” continues the Medicare Carriers Manual (chapter 12, section 30.6.7), “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.”
NOTE: The caveat here is specialty in the CMS directive which has historically been determined by taxonomy code. NPs and PAs have a different taxonomy code than physicians, so in a single specialty practice this shoe fits. It’s when it is a multi specialty group, same tax ID, that it becomes an issue. A physician can refer a patient to a different specialty physician within the group and it is a new patient visit – but it’s when the PA – who supposedly supports all the physicians in the group regardless, of specialty (although that may not be true) tries to refer to a different specialty that it gets muddy and insurers will always choose to deny the claim.