New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices

What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:

The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

*This response is based on the best information available as of 08/25/22.