New vs. Established Patient: The 3-Year Rule That Changes What You Get Paid
New-patient E/M codes pay more than established — but bill "new" when the rules say "established" and you invite recoupment. Here is exactly how the 3-year rule, specialty, and group practice decide the status.
"New or established?" seems trivial until you realize it's one of the most audited E/M questions there is — and one of the easiest to get wrong in a group practice. New-patient codes pay more, so the temptation is real, and the rules are more specific than most people remember. Here's the clean version.
Why it matters
New-patient E/M codes (99202–99205) reimburse more than established-patient codes (99211–99215), reflecting the extra work of a first encounter. That payment gap is exactly why auditors scrutinize new-patient billing — and why coding it correctly protects both your revenue and your compliance.
The 3-year rule
A patient is new if they have not received a professional, face-to-face service from you — or a same-specialty colleague in your group — within the previous three years. If they have, they're established. Simple on its face; the nuance is in "same specialty" and "same group."
Specialty and group practice
The determination hinges on the exact same specialty and subspecialty within the same group practice. So if a patient saw any provider of your specialty in your group in the last three years, they're established for you too — even on their first visit with you personally. Two providers of different specialties in the same group can each treat the same patient as new.
The 3-year clock belongs to the group and specialty, not the individual doctor. That's where most "new patient" overbills come from.
Edge cases worth knowing
- Interpretation only: reading an X-ray or EKG without a face-to-face service does not establish the patient.
- Different subspecialty: a genuinely different subspecialty in the group may support new-patient status — document it.
- Locum/coverage: a provider covering for another of the same specialty steps into that specialty for this rule.
Getting these right consistently is precisely what disciplined medical coding and a solid grasp of the E/M coding rules deliver.
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The bottom line
New pays more, but the 3-year rule ties status to your group and specialty, not just to you. Apply it correctly, remember interpretation-only doesn't count, and document genuine subspecialty differences. That's how you capture new-patient revenue you've earned without buying an audit. Start with a free billing audit.
Sources
Frequently asked questions
A patient is "new" if they have not received a professional (face-to-face) service from you — or from another provider of the exact same specialty and subspecialty in your group — within the previous three years. Otherwise they are "established."
The group and specialty combination. If any provider of the same specialty/subspecialty in your group practice saw the patient in the past three years, the patient is established — even if they are seeing a different physician for the first time.
No. Interpreting a diagnostic test without a face-to-face E/M or other face-to-face service does not, by itself, establish the patient.
New-patient E/M codes reimburse more than established-patient codes because they reflect the added work of a first encounter. Coding it wrong either underpays you or, if overstated, invites audit and recoupment.
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