Is a patient considered new after 3 years?

Yes, a patient is considered a new patient if they have not received any face-to-face professional services from the specific physician, or another provider of the exact same specialty and subspecialty in the same group practice, within the past three years.

The 3-Year Rule Details

• Timeframe: The three-year period is a strict rolling window calculated backward from the date of the current encounter. If it has been three years or longer since their last face-to-face visit, they are new.
• Provider and Specialty: If a different doctor in the same practice and exact same specialty saw the patient within the last three years, the patient remains an established patient.
• Different Specialties: If the patient saw a provider in a completely different specialty within the same group or health system in the last three years (such as a cardiologist instead of a dermatologist), they are still considered a new patient for the new specialty.
• Diagnostics vs. Face-to-Face: Merely reading an X-ray, lab result, or EKG without an actual face-to-face evaluation and management (E/M) service does not reset the three-year clock or make the patient "established".

According to the American Medical Association CPT Guidelines, proper coding relies heavily on verifying the patient's electronic health record history for the exact provider and specialty match.