Difference between new and established patients

New and Established Patients

To recognize the different levels of service between a patient that has not received care in a practice (and therefore needs more explanations regarding the operation of the practice) and an established patient (who is aware of the practice’s routines), there are different coding categories.  

New Patient – A new patient is a patient who has not received any professional services from the provider, or another provider of the same specialty, who belongs to the same group practice, within the past three years. 

A new patient may receive initial professional services as an inpatient or outpatient.  Subsequent professional services would be coded as an established patient.  The encounter used to determine a new or established patient is the first time a patient has an encounter that meets the criteria above, and meets the requirements of a “visit.”  Occasions of service will not be coded as a new patient encounter.  A common error in the DoD is when a pediatrician is involved with the delivery and initial hospitalization of the newborn, then the newborn is seen for the first well-baby visit.  The first well-baby visit would be an established patient.

Established Patient - An established patient is a patient who has received professional services from the provider, or another provider of the same specialty who belongs to the same group practice, within the past three years.  A common error in DoD is in optometry, when an optometrist new to the facility desires to code all patients as new.  The patients that had been seen in the optometry clinic by the previous optometrists in the past three years are all established patients to that optometry clinic.