A new interpretation of new versus established patients in the American Medical Association’s (AMA) 2023 evaluation and management (E/M) guidelines, which take effect Jan. 1, may cause some confusion because it doesn’t mesh with Medicare’s definition.^[1] A similar divergence exists with initial versus subsequent visits in the hospital, and because of that, providers should prepare for the reality of “conditional logic at the back end that varies by payer,” an expert said.

That’s one of the challenges facing providers as sweeping changes to E/M guidelines converge with the 2023 Medicare Physician Fee Schedule (MPFS) rule, said Richelle Marting, an attorney and certified coder in Olathe, Kansas. “CPT code changes don’t always align with the 2023 Medicare Physician Fee Schedule rule, so it’s important to take a look at what we know is changing in the code book and what CMS is proposing to do,” she said.^[2] There are similarities, differences and “gray areas,” some of which may change when CMS publishes the final MPFS rule at the end of October or early November. Also, the coding rules apply to telehealth services, although the long-term future of Medicare telehealth coverage is still hazy.

In terms of areas where the 2023 E/M guidelines and Medicare don’t mesh, the interpretation of new and established patients is a biggie, Marting said Oct. 3 at a Health Care Compliance Association webinar.^[3] The fundamental definition of a new-patient visit, which generates more reimbursement than an established-patient visit, hasn’t changed: new patients haven’t been seen by a provider or another provider of the same specialty or subspecialty in the same group practice in the past three years. According to clarifications in the 2023 E/M guidelines, when advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs), are working with physicians, they are considered to be working in the same specialty as the physicians. For example, in an orthopedic practice, the patient may be treated first by the orthopedic surgeon and then have a follow-up with the APP a month later. What does that mean in terms of a new versus established patient? “Under CPT, that’s an established patient visit because the patient has seen another provider of the same orthopedic specialty in the same group practice,” Marting said.