Evaluation and management (E/M) codes apply to visits and services that involve evaluating and managing patient health. E/M services include office and outpatient visits, hospital visits, home services, and preventive medicine services. As coders in a medical billing company know, selecting the correct code for many E/M services (office visits, hospital visits, home services, and preventive medicine services) starts with determining whether a patient is new or established. In the context of E/M coding, new patients and established patients are differentiated based on their prior relationship with a healthcare provider.
New patient visits typically involve:
- A more comprehensive assessment and evaluation.
- More time spent reviewing the patient’s history and establishing a treatment plan.
- The use of a higher level of coding due to the initial evaluation of the patient’s health history, concerns, and establishing care.
To choose between new patient codes 99201-99205 or established patient codes 99211-99215, it’s essential to understand the definition of new and established patients for E/M purposes.
Maximize reimbursement with specialized E/M coding services!
New Patient VS. Established Patient
New Patient
According to CPT, a new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
The Centers for Medicare & Medicaid Services (CMS) adds: 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.
Billing the correct E/M codes depends on understanding the three key elements that make up the “new patient” definition:
- Professional Service: If the provider has never seen the patient face to face, a new patient code should be billed. For instance, if a patient undergoes a blood test and the results are sent to an endocrinologist for analysis, but the patient sees the endocrinologist in person a week later for treatment of diabetes, a new patient E/M code is appropriate, as there was no face-to-face visit at the time the blood test was performed.
So, if a physician only interprets a diagnostic test without having a face-to-face consultation or direct interaction with the patient (no E/M service), it does not change the patient’s status from “new” to “established”.
- Three-year rule: A patient is considered new if they have not received any professional services from any provider within the same practice or group in the past three years. For example, if a patient visits a family practice in January 2025 but had their last visit with the same practice or group in December 2021, they would still be classified as a new patient for billing and documentation purposes.
- Different specialty/subspecialty within the same group: Physicians within the same group practice and specialty are required to bill and will be paid as if they were a single physician. Physicians from a different specialty can bill and receive payment regardless of their affiliation with a group. For Medicare patients, the coder can use the National Provider Identifier (NPI) registry to see under what specialty the physician’s taxonomy is registered. For other payers, this usually depends on the way the provider was credentialed.
New Patient Evaluation and Management (E/M) Codes
The new patient E/M codes are: 99201–99205. These codes are based on the type of history and medical decision making (MDM) involved in the visit:
- 99201: Problem-focused history and straightforward MDM. (Presenting Problem Severity- Self-Limited or Minor)
- 99202: Expanded problem-focused history and straightforward MDM (Presenting Problem Severity- Low to Moderate)
- 99203: Detailed history and low MDM. (Presenting Problem Severity- Moderate)
- 99204: Comprehensive history and moderate MDM. (Presenting Problem Severity – Moderate to High)
- 99205: Comprehensive history and high MDM. (Presenting Problem Severity Moderate to High)
Established Patient
CPT defines an established patient as “one who has received professional services from the physician or other qualified healthcare professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”
Established patient visits usually involve:
- Reviewing the patient’s progress and history but not as extensively as with a new patient.
- A focus on follow-up care, disease management, or treatment adjustments.
- Less time spent on history and examination since this information is already known.
Compared to new patient visits, established patient visits generally result in lower-level E/M codes unless there’s an increase in the complexity of care.
Established Patient Evaluation and Management (E/M) Codes
The established patient E/M codes are: 99211–99215 (for office or outpatient services). These codes also vary depending on the level of complexity and time spent on the visit.
99211: Office or other outpatient visit, typically 5 minutes, for evaluation and management.
99212: Office or other outpatient visit, typically 15 minutes, for evaluation and management.
99213: Office or other outpatient visit, typically 30 minutes, for evaluation and management.
99214: Office or other outpatient visit, typically 45 minutes, for evaluation and management.
99215: Office or other outpatient visit, typically 60 minutes, for evaluation and management.
Further Insights
Here are some different scenarios that further clarify the distinction between new and established patient:
- If a physician moves to a new practice and a patient follows them. if the patient sees their original physician there, the patient is considered an established patient for all physicians of the same specialty at the new practice.
However, if the patient sees another physician at the new practice before seeing their original physician, they are classified as a new patient for that physician.
- If a physician and a nurse practitioner (NP) work in the same office, and the physician initially sees a patient, the NP can still perform and bill for a new patient visit under the following conditions:
- The NP personally performs and documents the service.
- The service meets the criteria for a new patient visit.
- The NP bills using their own NPI (National Provider Identifier).
- If a family physician sees a new patient and refers them to a surgeon within the same group practice under the same tax ID, the patient is considered a new patient for the surgeon, provided the surgeon has not seen the patient in the past three years. This is because the two physicians belong to different specialties.
- A patient presenting with a new problem within three years of their last visit is considered an established patient.
- If professional services were rendered within the past three years, the patient is established.
- If it has been three years or more, the patient is classified as new.
The classification of a patient as new or established is based solely on the time elapsed since the patient last received professional services from the physician or another physician of the same specialty within the same group practice:
The nature of the problem (new or previous) does not affect this determination.
- In the emergency department, no distinction is made between new and established patients. Physicians with the same tax ID belong to the same group, regardless of their locations.
E/M Coding — What’s New in 2025?
Starting January 1, 2025, providers have new patient Evaluation and Management (E/M) codes:
- 98000–98003: Synchronous audio-video visits for new patients
- 98008–98011: Synchronous audio-only visits for new patients
These codes replace the old telephone-only codes 99441–99443.
Optimize E/M Coding with Expert Support
Understanding the difference between new patients and established patients is crucial for accurate billing. Accurate and thorough documentation is essential to support the selected code. Moreover, CPT codes can be revised annually, so always refer to the most current coding resources for updates. Utilizing professional medical billing and coding services is a practical strategy to accurately identify patient status and ensure compliance. This provides access to coders with extensive expertise in E/M coding, ensuring accurate and compliant billing for optimal reimbursement.
Enhance your medical billing efficiency and maximize your reimbursements!
More from This Author
