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24.3.12.1 New or Established Patient Visits
New patient visits will be allowed every three years for physician E/M services, per patient, per provider.
A new patient is defined by the AMA as one who has not received any professional services from a physician or physician within the same group practice, of the same specialty, within the past three years. An established patient is one who has received professional services from a physician or physician within the same group practice, of the same specialty, within the last three years.
Providers may use procedure codes 1-99201, 1-99202, 1-99203, 1-99204, and 1-99205 when billing for new patient services provided in the office, or in an outpatient or other ambulatory facility.
Providers may use procedure codes 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215 when billing for established patient services provided in the office, or in an outpatient or other ambulatory facility.
If an established patient visit is billed on the same day as a new patient visit in any setting by the same provider for any diagnosis, the established patient visit will be denied as part of another procedure on the same day. New or established patient care visits are limited to one per day for the same provider regardless of diagnosis.
Office visits (procedure codes 1-99201, 1-99202, 1-99203, 1-99204, 1-99205, 1-99211, 1-99212, 1--99213, 1-99214, and 1-99215) provided on the same day as a planned procedure (minor or extensive), are included in the cost of the procedure and are not separately reimbursed. An office visit provided for a separately identifiable service on the same day as a planned procedure, is considered for reimbursement with medical documentation. The modifier 25 should be appended to the E/M code to indicate that the evaluation was provided for a separately identifiable service.
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