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New Versus Established Patients in Workers’ Comp Billing

May 24, 2017 by Catherine Montgomery

One of the more vexing difficulties in workers’ compensation billing – and there are plenty of qualified candidates – is keeping up with the jargon. Abbreviations abound, and acronyms fly around like they’re going out of style. Crucially, certain terms or phrases that mean one thing when applied to most kinds of medical billing mean something different when applied to workers’ comp billing. (Longtime readers will remember that we’ve run into problems with terms like “original bill” before.) Today we tackle another such phrase, as it applies to the physician fee schedule: “New Patient.”

Per the Centers for Medicare & Medicaid Services (CMS) website, a “new patient” is defined thusly: “a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service... from the physician or physician group practice (same physician specialty) within the previous three years.”[1]

The Current Procedural Terminology (CPT) definition of a new patient is a little more restrictive – it limits the “new” classification to only those patients who have not received any professional services from any physician “of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”[2] (Emphasis ours.)

However, in the case of workers’ compensation evaluation and management coding, the  definition of new and established patient relates to whether the provider has previously treated the patient’s workers’ comp injury or illness. Per the California Division of Workers’ Compensation (DWC) Physician Fee Schedule Regulations, workers’ compensation billing uses its own definitions of “new” and “established” patients (emphasis ours):

“(1) A “new patient” is one who is new to the physician or medical group or an established patient with a new industrial injury or illness. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury or illness.
(2) An “established patient” is a patient who has been seen previously for the same industrial injury or illness by the physician or medical group.”
[3]

So say a new patient injured their finger. Their first visit to their workers’ comp provider would, of course, be coded as a new patient visit. But if the same patient later presents with a new injury, a knee sprain for instance, then the patient’s initial visit for that injury should also be coded as a new patient visit.

Absent a new injury, the patient is considered “established” for the purposes of workers’ comp – there’s no time limitation like the three years cited by the CMS and CPT.

To determine the correct level of evaluation and management at which to bill, coders must refer to either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.


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[1] See this CMS FAQ page for more information.

[2] More information available via the Happy Hospitalist blog.

[3] See § 9789.12.11 of the Physician Fee Schedule Regulations.

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