New Patient Visit Criteria

Published 03/19/2025

When billing Medicare, providers must choose the code that best characterizes the services rendered to the patient. The following elements should be taken into consideration when determining the appropriate code:

  • Patient type
  • Setting of the service
  • Level of evaluation and management (E/M) services provided 

Patient Type

For purposes of billing office and outpatient evaluation and management (E/M) services, the Centers for Medicare & Medicaid Services (CMS) defines patient type depending upon previous encounters with the provider. As per CMS, “a new patient is one who has not received any professional services (e.g., E/M service or other face-to-face service [e.g., surgical procedure]) from the physician or physician group practice (same physician specialty) within the previous 3 years.” CMS defines an established patient (PDF) as “a person who receives professional services from the physician, NPP, or another physician of the same specialty who belongs to the same group practice within the previous 3 years.”

Setting of the Service

The examples of setting categories recognized by CMS for E/M services include an office (or other outpatient setting such as an outpatient clinic), hospital inpatient, emergency department and nursing facility.

Level of E/M Service Provided to the Patient

E/M service codes are organized into categories and levels, the more complex the visit, the higher the level of code within the category. To bill any code, the services must meet the definition of the code and reflect the services provided. Medicare only pays for services that are considered medically necessary. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level is more appropriate. Providers must choose the visit level based upon the level of medical decision making (MDM) or the amount of time spent with the patient. CMS recommends utilizing the CPT E/M Guidelines for MDM (PDF). For all E/M visits, the history and physical exam must meet the descriptions in the code descriptors, but they don’t affect visit level selection. When using time to select the visit level, services must be provided for the full time. The general CPT rule about the midpoint for certain timed services does not apply. When using time to support billing the E/M visit, providers must document the time spent with the patient (using a start and stop time/total time) within the medical record). The chief complaint of the patient, as well as a detailed medical/surgical history, and physical examination must be documented in the medical record. 

When the appropriate coding has been determined, there are some additional aspects for an E/M visit that must also be considered prior to submission of a final bill/claim for the service.

Outpatient E/M Visits Provided on the Same Day 
The Medicare Administrative Contractors (MACs) will not pay two E/M office visits billed by a provider (or provider from the same specialty from the same group practice) for the same beneficiary on the same day unless medical record documentation supports that the visits were for unrelated problems that could not be cared for/treated during the same encounter.

MAC Edits
When the MAC discovers that a “new patient” code has been paid more than one time in a three-year period to the same physician, they are tasked with adjudication of the overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.

Codes that may be monitored include: 

  • CPT® codes: 99201–99205, 99324–99328, 99341–99345, 99381–99387, 92002 and 92004
  • The edits will also check to ensure that a claim with one of these new patient CPT® codes is not paid after payment of a claim with an established patient CPT® code (99211–99215, 99334–99337, 99347–99350, 99391–99397, 92012 and 92014)

References and Resources


Was this article helpful?