CommercialBilling CodesHigh impact
Correct coding: Established vs new patient
Blue Cross Blue Shield of Rhode Island·RI·Physician / Facility
Effective date
Dec 1, 2018
We identified it
Jun 20, 2026
Summary
BCBS Rhode Island clarifies coding guidelines for new vs. established patients, emphasizing that the 3-year rule applies across group practices within the same specialty, regardless of location changes or covering physicians. This affects proper E&M code selection and billing accuracy.
Action Required
Immediately: Billing team must review and update patient status verification procedures to ensure correct new vs. established patient coding. Train staff on the 3-year rule that applies across group practices within same specialty, including scenarios with covering physicians, location changes, and non-physician practitioners. Update encounter forms and billing system prompts to verify patient history before code selection. Incorrect patient status coding will result in claim denials or audit findings.