The Rule in One Sentence
A patient is established if they had a face-to-face professional service from you, or from another physician or qualified provider of the exact same specialty in your group, in the past three years. Otherwise the patient is new.
Medicare uses the same three-year rule, and decides "same specialty" by each provider's Medicare enrollment.
Why It Matters
| New patient | Established patient | |
|---|---|---|
| Office visit codes | 99202 to 99205 | 99211 to 99215 |
| Example: moderate visit, Medicare 2026 | 99204: $177.36 | 99214: $135.61 |
| Example: low visit, Medicare 2026 | 99203: $117.57 | 99213: $95.19 |
New patient visits pay more, so payers check them. Billing a new patient code for an established patient leads to recoding, denials or paybacks.
Ten Common Cases
| Situation | New or established? |
|---|---|
| You saw the patient 2 years ago | Established |
| You saw the patient 4 years ago | New |
| Your partner, same specialty, saw the patient last year | Established |
| A doctor in your group with a different specialty saw them last year | New |
| An NP or PA working with you saw the patient last year | Established (CPT treats them as your specialty) |
| You only read their EKG last year, without seeing them | New |
| You saw them by telehealth last year | Established |
| You saw them at your old practice 2 years ago, now you are in a new group | Established |
| You are covering for a colleague who saw them last month | Established (use the colleague's status) |
| They had a visit in the hospital with you 6 months ago | Established |
Medicare Details
- Medicare decides "same specialty" from each provider's primary specialty in Medicare enrollment.
- An interpretation of a test, such as reading an x-ray or EKG, without a face-to-face service does not make the patient established (Medicare Claims Processing Manual, Chapter 12, Section 30.6.7).
- If a physician moves to a new group, patients they saw in the past three years stay established to that physician.
- The rule applies across settings: a hospital visit counts the same as an office visit.
Related
Once you know the patient type, pick the level with the E/M code level calculator, or read 99213 vs 99214.
Frequently Asked Questions
Written by Hassan Raza Awan
Founder — LegitMedBilling & IT Solutions
Hassan has 4+ years of hands-on U.S. medical billing experience — working claims, denials, credentialing, and payer follow-up for practices across the United States. Every guide he publishes is written from real remittances and payer behavior, not theory.
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