Guidance for coding evaluation and management services for new and established patients

According to the American Medical Association (AMA) Current Procedural Terminology^® (CPT) guidelines, a new patient is defined as one who has not received any professional services, in other words, face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years. 

Effective with claims processed on or after February 1, 2023, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.

Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the claims payment dispute process (including submission of such documentation with the dispute) as outlined in the provider manual or resubmit the claim with an established patient E/M code.

If you have questions about this program, contact your contract manager or Provider Experience representative.