How Should We Code Previously Seen Patients in Our New Practice?

Carolyn Buppert, NP, JD


May 29, 2003


We are a new practice. We have nurse practitioners (NPs) who care for patients they saw at another practice. We have been advised that since this is a new practice, the patient's visit should be coded as a new patient rather than as an established patient charge since the patient is new to this practice. We have received conflicting information about which of these code sets to use.

Response From Expert

Carolyn Buppert, CRNP, JD
Nurse practitioner and attorney who specializes in the legal issues affecting medical practices and nurse practitioners. Buppert is the author of Nurse Practitioner's Business Practice and Legal Guide (1999) and The Primary Care Provider's Guide to Compensation and Quality (2000). She lectures extensively on avoiding malpractice, reimbursement issues, and negotiating contracts. Buppert can be reached at


Current Procedural Terminology (CPT) defines a "new patient as 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 3 years." An "established patient" is "one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years."[1] CPT adds: "In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available." CPT is a systematic listing and coding of procedures and services performed by physicians. The book, developed by the American Medical Association, has been adopted by most, if not all, third-party payers.

Assume that "nurse practitioner" may be substituted anywhere you see "physician" in the CPT code book. If an NP saw a patient within 3 years, he is an established patient for the NP. Use the CPT codes for established patients.

Note that if you used the new patient codes, not only would you need to meet the definition above of "new patient," but you would also need to meet the performance and documentation criteria for new patient visits. For a new patient visit, the provider must meet the requirements for history taking, examination, and medical decision making for the level of service billed. For example, if you performed a level 4 history, a level 4 examination, and level 2 medical decision making on a new patient, you could bill for only a level 2. If the patient was an established patient and you did this work, you could bill a level 4. So, an auditor could challenge your choice of new patient code on 2 fronts; ie, that the patient did not meet the definition of "new," and/or that you did not meet the criteria for the level of visit you billed.


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