Evaluation Management - New Patients Vs Established Patients

The E/M codes are categorized based on the service rendered in the setting and or location. 

Examples,

• Office or other outpatient setting 
• Emergency department (ED) 
• Hospital inpatient 
• Nursing facility (NF)

Patient Type 

For the billing purpose and the code selection will be depending on the service performed with the same physician either new patients or established patients. 

New Patient

An individual who did not receive any professional services from the physician and or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty  who belongs to the same group practice within the previous 3 years

Established Patient

An individual who receives professional services from the physician or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty who belongs to the same group practice within the previous 3 years.

Key Components 

The E/M codes are mostly selected based on three major key components to electing the appropriate level of E/M services

Major Key Components 

• History
• Examination
• Medical Decision Making (MDM)

Other Contributing Factors 

The E/M codes are rarely selected based on the Contributing Factors

• Counseling
• Coordination of care
• Nature of presenting problem
• Time.

2021 Changes

CPT code 99201 (new patient, level 1) deleted from Jan 1, 2021 and the CPT code 99211 l remain as a reportable service

The first two major key components of History and Physical Examination removed as key components for selecting the level of E&M service for office and or outpatient services (CPT 99202 to 99215).

In  before 2021, history and exam are two of the three components used to select the appropriate E&M service.

From Jan 2021, history and exam will no longer be used to select an E&M service for office and or outpatient visits, but still must be performed and documented in the medical record in order to selecting the appropriate CPT codes 99202-99215.

For 2021 E&M Changes