New Versus Established in the Office

Question:

We are an otolaryngology practice, and we added a facial plastic surgeon to our group. If he sees one of our established patients for the first time in the office, would that be a new or established patient for the plastic surgeon? He does not share the same taxonomy or specialty code with our Otolaryngologists and is credentialed as specialty code 24.

Answer:

This is a great question. Since the Facial Plastic surgeon is credentialed as specialty 24 and Otolaryngology is credentialed as specialty 04, the patient would be considered a new patient for the plastic surgeon. Understanding the coding rules for new versus established patients in the office or outpatient setting is important.

A new patient has not received any professional services from the physician or other qualified health care 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.

An established patient has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the same specialty and subspecialty who belongs to the same group practice within the past three years.

*This response is based on the best information available as of 10/17/24.