Q. What is the updated definition of “new patient” for billing evaluation and management (E/M) services?

A. The Medicare Claims Processing Manual (Chapter 12, Section 30.6.7) now defines “new patient” for the E/M visit code and reads as follows: Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

For example, if a professional component of a previous procedure is billed in a three-year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.

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.

Source: Centers for Medicare & Medicaid Services