Glossary · Coding
New vs. established patient
A new patient has not received any face-to-face professional service from the billing provider or any provider of the exact same specialty and subspecialty in the same group practice within the past three years. An established patient has received such a service within that window.
Verified May 8, 2026 · 9 sources ↓
Definition
Source · Editorial summary grounded in 9 cited references ↓
The distinction hinges on three factors: (1) face-to-face contact, (2) specialty and subspecialty match, and (3) the 36-month lookback period. A patient is new if no provider sharing the same specialty, subspecialty, and group-practice billing identity has delivered a face-to-face service within the prior three years. If any such provider has done so, the patient is established for all providers of that same specialty in the group—regardless of which location the visit occurs at or whether the presenting problem is different.
Face-to-face contact is the threshold requirement. Interpreting an imaging study, reading an EKG, or calling in a prescription does not constitute a professional service for this purpose. A patient whose X-ray was read remotely by an orthopedic surgeon in the group, but who has never had an in-person visit with anyone in that group's orthopedic specialty, is still a new patient when they first walk through the door.
Specialty and subspecialty boundaries matter under both CPT and CMS rules. A general orthopedic surgeon and a hand surgeon may carry different Medicare taxonomy codes; if CMS recognizes them as distinct subspecialties, each provider can legitimately bill a new-patient visit for the same patient. Non-physician practitioners (NPs, PAs) working alongside physicians are treated as belonging to the same specialty and subspecialty as those physicians for this purpose. New providers joining an existing group practice inherit the established-patient relationships of the group for the specialties they share.
Why it matters
New-patient E/M codes (99202–99205) carry higher relative value units than their established-patient counterparts (99211–99215), so miscategorization directly affects reimbursement. Billing a new-patient code for a patient seen within the past three years by a same-specialty colleague in the group is a common audit target and can trigger claim denials, overpayment demands, or, in pattern cases, compliance scrutiny. Conversely, defaulting every returning patient to an established-patient code when the 36-month window has expired leaves legitimate revenue on the table.
Common mistakes
Where people most often go wrong with this concept.
Source · Editorial brief grounded in cited references ↓
- Treating a patient as established solely because they have a chart in the system—chart presence does not equal a qualifying face-to-face visit within the lookback period.
- Assuming a radiologist or surgeon who interpreted an imaging study 'already saw' the patient, making them established—remote interpretation with no in-person encounter does not trigger established status.
- Billing new-patient codes because the patient is presenting with a new clinical problem—a different diagnosis does not restart the three-year clock.
- Overlooking that a hand surgeon and a general orthopedic surgeon in the same group may hold separate CMS taxonomy codes, allowing each to bill a new-patient visit for the same patient.
- Classifying urgent-care or walk-in visits as automatically new—the same three-year, same-specialty, same-group rules apply regardless of visit setting.
- Forgetting that NPs and PAs in the practice share the supervising physician's specialty designation, so their prior visits count toward established status.
- Failing to verify the actual date of the last face-to-face encounter before coding—relying on registration data or 'last appointment' fields that may include phone calls or prescription refills.
Related codes
Codes commonly involved when this concept appears in practice.
CPT
- 99203 $117.57New patient office or outpatient visit requiring a medically appropriate history and/or examination with low-complexity medical decision-making, or 30–44 minutes of total provider time on the date of the encounter.
- 99204 $177.36New patient office or outpatient visit requiring moderate medical decision making, or 45–59 minutes of total provider time on the date of the encounter.
- 99205 $236.81New patient office or outpatient visit requiring high-complexity medical decision making, or 60–74 minutes of total time on the date of encounter.
- 99213 $95.19Established patient office or outpatient visit requiring 20–29 minutes of total time or low-complexity medical decision-making.
- 99214 $135.61Office visit for an established patient requiring moderate-complexity medical decision making (MDM), or 30–39 minutes of total provider time on the date of service.
- 99215 $192.39Highest-level office or outpatient E/M visit for an established patient, qualifying via high-complexity medical decision making or 40–54 minutes of total provider time on the date of service.
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 9 cited references ↓
01Does seeing a patient for a brand-new diagnosis make them a new patient?
02If a patient switches from one orthopedic surgeon to a different orthopedic surgeon in the same group, are they new?
03A radiologist in our orthopedic group read a patient's MRI two years ago. Is that patient established?
04How do non-physician practitioners affect patient status?
05What if more than three years have passed since the last visit?
06Do the new-vs.-established rules apply to all E/M codes?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01aapc.comhttps://www.aapc.com/codes/coding-newsletters/my-orthopedic-coding-alert/3-steps-determine-new-vs-established-patient-status-article
- 02med.noridianmedicare.comhttps://med.noridianmedicare.com/web/jeb/specialties/em/new-vs-established-patient
- 03cmadocs.orghttps://www.cmadocs.org/newsroom/news/view/ArticleId/27217/Coding-Corner-How-coding-guidelines-define-new-vs-established-patients
- 04aafp.orghttps://www.aafp.org/pubs/fpm/issues/2003/0900/p33.html
- 05aapc.comhttps://www.aapc.com/blog/41276-new-vs-established-patients-whos-new-to-you/
- 06racmonitor.medlearn.comhttps://racmonitor.medlearn.com/new-versus-established-patients-do-you-know-the-rules-and-exceptions/
- 07bcbsri.comhttps://www.bcbsri.com/providers/update/correct-coding-established-vs-new-patient-0
- 08CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.7
- 09CMS Change Request 4032 (Transmittal R731CP)
Mira AI Scribe
When Mira auto-selects between a new-patient (99202–99205) and established-patient (99202–99215) E/M code, it checks three conditions in sequence: (1) Has any provider sharing this provider's exact specialty and subspecialty within the same billing group rendered a face-to-face service for this patient in the past 36 months? (2) Does the practice's EHR or scheduling data contain a qualifying encounter date, or only non-face-to-face touchpoints such as test interpretations, phone encounters, or prescription refills? (3) Does the rendering provider's CMS taxonomy code differ from other orthopedic providers in the group (e.g., hand surgery vs. general orthopedic surgery), potentially supporting a new-patient designation? If the answer to question 1 is no—or if all prior contacts fail the face-to-face test in question 2—Mira flags the encounter for a new-patient code and prompts the coder to confirm. If taxonomy separation is detected under question 3, Mira surfaces a advisory note recommending coder review before finalizing. Mira does not override a coder's manual selection but will generate a compliance note if an established-patient code is applied where no qualifying face-to-face encounter appears in the linked record within 36 months, or vice versa.
See Mira's approach