CommercialBilling CodesHigh impact
Correct coding: Established vs new patient
Blue Cross Blue Shield of Rhode Island·RI·Physician
Effective date
Mar 1, 2024
We identified it
Jun 19, 2026
Summary
BCBSRI clarifies coding guidelines for new vs established patients following AMA CPT definitions. A new patient has not received face-to-face services from any physician in the same specialty/subspecialty within the same group practice in the past 3 years. The policy provides specific examples including practice location changes, covering physicians, and nurse practitioner encounters.
Action Required
Immediately: Billing team must review and update patient status determination processes to ensure compliance with CPT guidelines. Train staff on the 3-year rule and same specialty/subspecialty requirements. Update billing system logic to properly identify new vs established patients based on face-to-face encounters within group practice. Review recent claims to ensure proper coding of evaluation and management visits.