Does a telehealth visit reset the 3-year clock for new patient status?

Yes. A telehealth visit counts as a face-to-face professional service under current CMS guidelines. If you see a patient via video in 2024, they remain established until 2027. Audio-only visits also count if billed as E/M encounters with the appropriate modifier.

Can a patient be new to one specialty and established with another in the same group?

Yes. The new/established determination is specialty-specific within a group practice. A patient who has been seeing your family medicine provider for years is still a new patient for their first visit with your group's dermatologist. Bill the dermatology visit using new patient codes.

What if a patient was seen by a locum tenens physician — does that count for the 3-year rule?

It depends on how the locum was credentialed. If the locum billed under their own NPI as the same specialty, that encounter counts. If the locum billed under the supervising physician's NPI using modifier Q6, the encounter is attributed to the supervising physician and counts toward their 3-year window.

Is there a CPT 99201 code for minimal new patient visits?

No. CPT 99201 was deleted effective January 1, 2021, when the AMA 2021 E/M guidelines took effect. The lowest new patient code is now 99202, which requires at minimum straightforward medical decision making. There is no new patient equivalent of 99211.

New Patient vs Established Patient E/M Codes: Why the Distinction Costs You Money

The difference between a new patient visit and an established patient visit is not just a clinical distinction — it is a reimbursement gap of 30–50% at every code level. A 99204 (new patient, moderate complexity) reimburses approximately $210, while the equivalent established patient code 99214 reimburses approximately $130. That is $80 per visit — and the documentation requirements are the same.

Yet most practices misclassify patients routinely. They bill established patient codes for patients who technically qualify as “new,” and they fail to track the 3-year rule that reverts established patients back to new patient status. The result is a silent, compounding revenue leak that grows with every misclassified encounter.

The Definition That Determines Your Reimbursement

CMS and the AMA define a “new patient” with a specific three-part test:

A patient is “new” if they have not received any professional services from the physician, or from another physician of the same specialty who belongs to the same group practice, within the past 3 years.

Breaking this down:

“Professional services” means face-to-face services. A phone call, lab order from a covering physician, or prescription refill does not count as a professional service for this definition.
“Same specialty” means the same specialty or subspecialty recognized by their credentialing. A cardiologist and a primary care physician in the same group are different specialties — a patient can be “new” to the cardiologist even if established with the PCP in the same group.
“Past 3 years” is measured from the date of the previous face-to-face encounter. If a patient last saw you on March 15, 2023, they revert to “new” on March 16, 2026.

The Code Ranges and Reimbursement Gap

Here are the two E/M code sets with approximate 2024 National Medicare reimbursements:

New Patient Codes (99202–99205)

99202 (straightforward MDM or 15–29 min): ~$76
99203 (low MDM or 30–44 min): ~$114
99204 (moderate MDM or 45–59 min): ~$210
99205 (high MDM or 60–74 min): ~$268

Established Patient Codes (99211–99215)

99211 (minimal, may not require physician presence): ~$24
99212 (straightforward MDM or 10–19 min): ~$57
99213 (low MDM or 20–29 min): ~$80
99214 (moderate MDM or 30–39 min): ~$130
99215 (high MDM or 40–54 min): ~$184

The Gap at Each Level

Straightforward: $76 vs $57 = 33% more for new patients
Low: $114 vs $80 = 43% more for new patients
Moderate: $210 vs $130 = 62% more for new patients
High: $268 vs $184 = 46% more for new patients

The reimbursement gap reflects CMS’s recognition that new patient encounters require more cognitive work: building a history from scratch, reviewing transferred records, establishing a treatment plan without prior context, and performing a more comprehensive evaluation.

The 3-Year Rule: When Established Patients Become New Again

This is the most commonly missed revenue opportunity in the new vs. established patient distinction:

If a patient has not had a face-to-face encounter with you (or a physician of the same specialty in your group) for 3 full years, they revert to “new patient” status.

Common scenarios where this applies:

Patients who moved away and returned. A patient who left your area in 2022 and comes back in 2026 is a new patient.
Patients with episodic conditions. A dermatology patient treated for acne in 2022 who returns for a new concern in 2026 is new.
Patients who switched providers and came back. Three years without a face-to-face visit resets the clock regardless of the reason.
Patients of retired or departed physicians. If Dr. Smith left the group 3+ years ago and the patient now sees Dr. Jones (same specialty), the patient may be new to Dr. Jones.

Revenue impact: if you see just 5 patients per month who are classified as established but actually qualify as new, you are losing approximately:

5 patients × $80 average gap × 12 months = $4,800/year in lost revenue

For larger practices with multiple providers, this number scales proportionally.

Common Classification Mistakes

These errors cost practices real money:

Mistake 1: “They are in our system, so they are established”

Your EHR having a patient record does not make them “established.” The test is face-to-face service within 3 years, not existence in your database. A patient with a chart from 2019 who walks in today is a new patient.

Mistake 2: Counting phone calls or refills as establishing the relationship

A covering physician who took a patient’s phone call, sent a prescription refill, or reviewed labs without a face-to-face encounter did not “see” the patient for the purposes of this definition. The clock continues running.

Mistake 3: Same group, different specialty — billing as established

If a patient is established with your group’s family medicine providers but has never seen your group’s cardiologist, that first cardiology visit is a new patient visit. The specialties are tracked independently.

Mistake 4: Not tracking the 3-year anniversary

Most EHRs do not automatically alert you when a patient crosses the 3-year threshold. Without a system to flag these patients, your schedulers and billers default to “established” because the patient has a chart. This requires a proactive workflow.

Mistake 5: Confusing the referring physician relationship

A referral from another physician does not transfer the “established” status. Even if Dr. Brown has seen the patient for years, when she refers to your practice, the patient is new to you.

How This Affects Practice Revenue Modeling

Understanding new vs. established patient mix is critical for practice financial planning:

Revenue per Visit Projections

A practice that sees 15% new patients (vs. 10%) at the moderate complexity level generates:

100 daily encounters × 5% additional new patients × $80 gap = $400/day additional revenue
Annualized: $100,000+ in revenue difference from accurate classification alone

New Provider Ramp-Up

When a new physician joins your group, their first 12–18 months involve a disproportionate share of new patients. Financial models that use blended established/new rates underestimate early revenue. Budget using 40–60% new patient rates for year one.

Specialty Conversion Revenue

Internal referrals between specialties within a group practice each generate new patient revenue. A primary care practice that adds a behavioral health provider, for example, can bill 99204 for every shared patient’s first psychiatry visit — even if they have been seeing the PCP for years.

Documentation: New Patient vs Established

Under AMA 2021 guidelines, the MDM documentation requirements are identical for new and established patients at each complexity level. The difference is:

New patients do not have a 99201 equivalent. The lowest new patient code (99202) requires at minimum straightforward MDM. There is no “minimal” new patient code.
Time thresholds are higher for new patients. 99204 requires 45–59 minutes, while the equivalent-MDM 99214 requires only 30–39 minutes. This reflects the expected additional time for new patient encounters.
History and exam are no longer scored. Under the 2021 framework, a “comprehensive history” is no longer required for new patients. Code by MDM or time, regardless of patient status.

The clinical reality is that new patient encounters almost always involve more time (records review, building rapport, comprehensive assessment). This naturally supports either a higher time-based code or, when combined with diagnostic uncertainty and treatment initiation, a higher MDM level as well.

Workflow: Catching New Patient Opportunities

Implement these steps to ensure accurate classification:

Run a quarterly “3-year report.” Query your EHR for patients whose last face-to-face visit was 3+ years ago. Flag them as potentially “new” for scheduling purposes.
Train scheduling staff. When a patient calls after an extended absence, the scheduler should ask: “When was your last visit with us?” If the answer is 3+ years, schedule as a new patient appointment (longer slot, higher reimbursement).
Verify at check-in. Front desk confirms last visit date. If 3+ years, the encounter is coded as new patient.
Track specialty-specific status. For multispecialty groups, maintain per-specialty patient status. A patient can be established with cardiology and new to endocrinology simultaneously.
Use AI pre-coding analysis. CodeItRight flags encounters where the patient status and documentation suggest new patient coding may apply, alerting you before claim submission.

Payer Considerations

While CMS defines the standard, payer-specific nuances exist:

Medicare: Strictly follows the 3-year/same-specialty rule. Well-defined, rarely disputed.
Commercial payers: Most follow the Medicare definition, but some (notably certain BCBS plans) have their own interpretations. Check contracts.
Medicaid: State-specific. Some states use 2 years instead of 3. Verify with your state Medicaid manual.
Medicare Advantage: Follows traditional Medicare definitions unless the plan-specific contract states otherwise.

One key audit trigger: billing a disproportionate number of new patient codes relative to your peer group. If your new patient rate is significantly higher than specialty norms, ensure your classification logic is defensible. Audit-ready documentation of the 3-year gap (date of last visit clearly stated in the record) protects against these flags.

How CodeItRight Handles New vs Established

When you analyze a note with CodeItRight’s AI engine, the system produces dual codes for both new and established patient scenarios when applicable. This means:

You see both 99203 and 99213 (or 99204 and 99214) side by side
The reimbursement gap is displayed, so you immediately see the revenue impact of correct classification
Time-based and MDM-based codes are calculated for both categories
Gap analysis flags if the note’s complexity suggests new patient coding may be more appropriate

This eliminates the guesswork. Your biller confirms the patient’s status, selects the correct code set, and submits the claim knowing the documentation supports the level billed.