What’s the Meaning of Established Patient & Examples of It?

Understanding the definition of an established patient and how it differs from a new patient is essential in healthcare billing and coding. The terms have unique meanings, each affecting reimbursement and administrative decisions. 

What is an Established Patient?

An established patient is defined as a person who has received professional services from the same physician or qualified healthcare provider within the past three years. This includes face-to-face services from the provider or another provider with the same specialty within the same group practice. This standard applies across most billing situations, allowing practices to classify patients accurately and ensure compliant coding.

Professional Services and Established Status

Professional services refer to direct, face-to-face evaluations and management services, including checkups, diagnoses, and procedures. Diagnostic interpretations alone, such as reading an X-ray or electrocardiogram (EKG), do not affect the patient’s classification. Even if a physician interprets a test but has not provided an in-person service, the patient remains classified as new for billing purposes until they have a direct visit with that physician or another provider within the same specialty.

Established vs. New Patient: Key Differences and Why They Matter

The primary difference between new and established patients lies in the timing and nature of previous services received. A new patient has not received any in-person care from the physician or any member of the same specialty within a group practice in the last three years. In contrast, an established patient has visited the provider or another provider in the same specialty within the three-year timeframe.

The Three-Year Rule

A clear three-year rule distinguishes established patients. If a patient received an in-person service from the provider within the past three years, they are considered established. If three years have passed since their last visit, they qualify as a new patient, even if they return to the same provider. This rule simplifies patient classification and helps prevent billing inconsistencies.

Why Does Classification Matter?

The difference between new and established patients affects reimbursement. New patient codes have higher relative value units (RVUs), reflecting the additional time and resources required to assess and develop a treatment plan for patients without an existing history. Providers who misclassify established patients as new patients could face claim denials or audits from payers, who often scrutinize new patient billing codes more closely. Accurate classification ensures practices receive proper compensation and avoid administrative complications.

Practical Examples of an Established Patient

Example 1: Return Visit in a Specialized Clinic

Imagine a patient who initially consults with a dermatologist, Dr. Lee, for a skin condition at a dermatology clinic. Six months later, the patient returned with a new concern about a recurring rash. This time, the patient is treated by Dr. Kim, another dermatologist within the same clinic. Because Dr. Lee and Dr. Kim share the same specialty within the same group, the patient is classified as established, even though they’re seeing Dr. Kim for the first time.

Example 2: Follow-up Visit After Clinic Relocation

Consider a patient who previously visited Dr. Tran, a family medicine doctor, at a clinic located in a small town. Dr. Tran later moves to a larger city and begins practicing at a new clinic. When the patient decides to travel to Dr. Tran’s new office for their next visit, they retain their established status because they have already received face-to-face care from Dr. Tran within the last three years, even though the clinic’s address and tax ID have changed.

Special Considerations in Established Patient Classification

Advanced Practice Providers (APPs) and Established Patient Classification

Advanced Practice Providers (APPs), such as nurse practitioners and physician assistants, often work in conjunction with physicians. When APPs operate within the same specialty and subspecialty as the physician, their encounters count toward the patient’s status in that specialty. However, if the APP practices a different specialty, they may treat a patient as new, depending on the services provided and the payer’s guidelines.

Exceptions to the Rule: Emergency Departments and Medicaid Plans

Certain scenarios exempt established patient classifications. For example, emergency department services generally do not distinguish between new and established patients, as they are billed on a per-visit basis. Additionally, some Medicaid programs require providers to use a new patient code for the first prenatal visit, even if the provider has seen the patient previously, to support comprehensive care.

Taxonomy and Credentialing Factors

Credentialing details, like taxonomy numbers and specialty listings in payer registries, help identify provider specialties when determining established status. Medicare and other payers rely on National Provider Identifier (NPI) registries to confirm a provider’s specialty, streamlining compliance and reducing billing inconsistencies.

Correctly Applying Established Patient Status in Billing

Medical record documentation plays a significant role in ensuring patients are accurately classified as established or new. Proper records can substantiate claims, clarify the patient’s visit history, and reduce the likelihood of billing errors. When billing for Evaluation and Management (E/M) services, healthcare providers should carefully select the E/M code that accurately reflects the patient’s status and service complexity.

Common Mistakes in Billing

Common errors in patient classification include failing to follow the three-year rule, incorrectly categorizing patients due to practice location changes, and misunderstanding the nuances of provider specialties within group practices. Avoiding these mistakes helps providers receive proper reimbursement and maintain compliance.

How Patient Engagement Software Helps with Established Patient Care

With features that simplify communication, organize records, and enhance the patient experience, this software supports a smooth and connected care process. Here’s how it helps with managing established patients:

1. Easy Appointment Scheduling and Reminders

Scheduling regular check-ups or follow-up visits becomes much simpler with patient engagement software. Patients can quickly book appointments online without needing to call the office, and they’ll get automatic reminders. 

2. Personalized Messages and Follow-ups

For established patients, personalized care makes a big difference. Patient engagement software allows providers to send tailored follow-up messages, share health tips, or remind patients about necessary screenings. 

3. Quick Access to Medical Records

With patient engagement software, reviewing an established patient’s medical history is quick and convenient. Doctors can easily see past visits, treatments, and test results, helping them provide more informed and efficient care. Patients also benefit from being able to access their records, giving them a better understanding of their health.

4. Better Patient-Provider Connection

Staying connected between visits helps build a stronger relationship between patients and providers. Patient engagement software allows patients to reach out with questions, request medication refills, or view test results—all through a secure messaging system. 

5. Smoother Billing and Insurance Processing

Patient engagement software can also simplify billing by keeping track of visit dates and patient type (new or established). This helps avoid billing mistakes and reduces the chance of insurance claim denials, saving time and reducing stress for both the patient and the provider.

Beyond Established vs. New: Adapting to Evolving Standards

Staying informed about billing standards and guidelines for patient classification ensures that practices can navigate the complexities of healthcare billing. The established vs. new patient distinction may seem minor, but it significantly affects coding, reimbursement, and compliance. Accurately determining whether a patient qualifies as new or established allows practices to maximize efficiency, reduce billing errors, and focus on delivering quality care.