WPS recently enhanced our claims editing software related to new and established patients. Our policies apply the AMA (American Medical Association) and E/M (Evaluation and Management) guidelines. You could receive denials when reporting a new patient visit.
Per AMA guidelines, a new patient is defined as “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care profession of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.” When advanced practice nurses and physician assistants are working with a physician, they are considered as working in the same subspecialties as the physician.
If you have questions related to this policy, please refer to the guidelines and decision tree referenced in the 2017 CPT Professional Edition. Further questions can be directed to our Customer Service department at 800-765-4977.