When can you bill for a new patient?

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You can bill a new patient visit code when the patient has not received any face-to-face professional services from the same physician or a physician of the same specialty in the same group practice within the past three years.

Key Rules for New Patient Billing

  • The 3-Year Rule: At least 36 months must pass since the last face-to-face encounter with that specific provider or same-specialty peer in the practice.
  • Group and Specialty Focus: The clock follows the provider specialty and group practice (identified by the same tax ID), not just an individual doctor. If a patient sees a different specialty within the same multi-specialty group, they may still qualify as a new patient.
  • Indirect Services Exception: Reading an X-ray, interpreting an EKG, or performing lab work without a face-to-face visit does not make the patient established. The subsequent first face-to-face visit can still be billed as a new patient visit.
  • Administrative Contacts: Phone calls, patient portal messages, or refill requests do not establish a patient relationship.

Can I bill a new patient after 3 years?

Yes, you can bill a patient using new patient codes if they have not received any face-to-face professional services from you or another physician of the exact same specialty in your group practice within the past three years.

The 3-Year Rule Basics

  • Timeframe: The patient must not have had an evaluation and management (E/M) or other face-to-face visit with your practice in 36 months.
  • Specialty and Group: The rule applies to the AAPC Guidelines across the same group practice and exact specialty. If a different provider in your group and specialty saw them recently, they are established.
  • Exclusions: Non-face-to-face services like phone calls, portal messages, or reading lab results/X-rays do not reset or create established status on their own.

What is the CMS rule for new patients?

Under the Centers for Medicare & Medicaid Services (CMS) guidelines, a new patient is an individual who has not received any professional, face-to-face services (such as an Evaluation and Management [E/M] visit or a surgical procedure) from the specific physician—or another physician of the same exact specialty and subspecialty in the same group practice—within the past three years.

Key Elements of the CMS Rule

  • The Three-Year Window: If a patient has not seen the provider or a peer in that exact specialty/group for 36 months, they revert to "new patient" status.
  • Group Practice & Specialty: The rule applies to the group practice (identified by the same tax ID) and the physician's specific specialty, not just an individual doctor. If a patient sees a different specialist within the same multi-specialty group, they may still qualify as a new patient for that specific specialist.
  • Diagnostic Tests Exception: Reading a lab result, X-ray, or EKG without a face-to-face encounter does not count as a professional service that changes a patient from "new" to "established".
  • On-Call and Coverage: If a covering or on-call physician bills under the same tax ID for a practice the patient has already visited within three years, the patient remains an established patient.

How long after a date of service can you bill a patient?

Providers can typically bill a patient within 30 to 180 days after the date of service, but exact deadlines depend heavily on insurance processing rules and state laws.

General Billing and Insurance Timelines

  • Insurance Claim Filing: Providers generally must submit claims to insurance plans within 90 to 365 days, depending on the payer. Medicare requires claims within 12 months.
  • Patient Billing Window: After insurance processes or denies a claim, providers usually send the patient a balance statement within 30 to 60 days.
  • Insurance Delays: Complex claims, coding audits, or coordination of benefits can delay the final patient bill for several months.

State-Specific Laws

  • Strict Limits (e.g., Texas): Some states enforce specific timely billing laws. For instance, the Texas Health and Human Services Commission enforces rules requiring providers to bill patients no later than the first day of the 11th month after care, or risk losing the right to collect.
  • No Hard Limit (e.g., Washington): Many states do not set a strict statutory cap on the initial patient bill date, though consumer protection rules or debt collection waiting periods (such as a 120-day delay before collections in Washington) still apply.

Debt Collection and Statutes of Limitations

  • Statute of Limitations: If a bill goes unpaid, the legal window for a provider or collection agency to sue for medical debt typically ranges from 3 to 10 years, depending on state laws governing written contracts.
  • Credit Reporting: Under nationwide credit reporting rules, paid medical debt cannot be reported, and unpaid medical debt under specific dollar thresholds or under one year old generally cannot appear on credit reports.

What is the Medicare 14 day rule?

The Medicare 14-day rule is a Centers for Medicare & Medicaid Services regulation that determines the date of service (DOS) for laboratory tests and dictates whether an outside laboratory or a hospital bills Medicare.

How the Rule Works

  • Date of Collection vs. Performance: For standard clinical diagnostic lab tests, the date of service is set as the date the specimen was collected, not the date the test was actually run.
  • The 14-Day Window: If a physician orders a test less than 14 days after a patient is discharged from a hospital (inpatient or outpatient), the hospital is responsible for billing Medicare directly for the test. The outside reference laboratory must then seek payment from the hospital instead of Medicare.
  • After 14 Days: If the test is ordered 14 days or more following discharge, the date of service shifts to the date the test was performed, and the outside laboratory can bill Medicare directly.

Exceptions to the Rule

The Centers for Medicare & Medicaid Services created exceptions for certain specialized tests, such as Advanced Diagnostic Laboratory Tests (ADLTs) and specific molecular pathology tests.

  • For these exempt tests, the date of service is always the date the test was performed, regardless of when it was ordered or if it falls within the 14-day post-discharge window.
  • This allows independent laboratories to bill Medicare directly for critical genomic and molecular diagnostics rather than coordinating billing through the hospital.

Schedule a New Patient

9 related questions found

Is a patient considered new after 2 or 3 years?

A patient is considered a new patient if they have not received any face-to-face professional services from the specific provider—or another provider of the exact same specialty and subspecialty in the same group practice—within the past 3 years.

The 3-Year Rule

  • New patient: No face-to-face visit with the provider or same-specialty group member in 36 months (3 years) or more.
  • Established patient: Seen face-to-face by the provider or same-specialty group member within the past 3 years.
  • Exact timing: The 3-year limit is a hard date-to-date boundary, not based on calendar years. A visit 2 years and 11 months ago makes the patient established, while 3 years and 1 day makes them new.

Important Details

  • Group practices: If you see a different doctor at the AAPC clinic who shares your first doctor's exact specialty, the 3-year clock applies to the whole group.
  • Different specialties: If a patient sees a cardiologist in a multi-specialty group, they are still a new patient when visiting a dermatologist in that same group for the first time.
  • Test readings only: Reading an X-ray, lab, or EKG without a face-to-face evaluation does not count as a professional service to reset the clock. Read more guidelines from the American Academy of Ophthalmology on multi-practice billing rules.

What are the Medicare incident to billing guidelines for 2026?

Medicare incident-to billing allows services furnished by auxiliary staff or non-physician practitioners to be billed under a supervising physician's NPI at 100% of the Physician Fee Schedule, rather than 85%.

✅ Core Requirements

  • Noninstitutional setting: Must occur in an office or clinic, not a hospital or skilled nursing facility.
  • Physician initiation: The physician must personally perform an initial service and establish a plan of care.
  • Active involvement: The physician must remain actively involved in the ongoing treatment.
  • Direct supervision: The physician must be immediately available; as of 2026, real-time audio-video is permanently permitted (excluding audio-only).
  • Employment relationship: Staff must be direct employees or independent contractors under the billing physician/group.
  • State scope of practice: Services must comply with state licensing laws for the specific auxiliary personnel.
  • Integral part: The service must be a standard, incidental part of the visit, not a brand-new primary complaint.

How often can a new patient visit be billed?

A new patient visit can typically be billed only once every three years (36 months plus one day) per patient, per physician, or by physicians of the same exact specialty and subspecialty within the same group practice.

Core Billing Rules

  • The 3-Year Rule: A patient is considered "new" only if they have not received any face-to-face professional services from that specific provider (or the same specialty/subspecialty in that practice) in the past 3 years.
  • Same Specialty/Group Limitation: If a patient saw a pediatrician in a multi-specialty group 2 years ago, and now sees a cardiologist in that same group, the cardiologist can bill a new patient code because the specialty is different.
  • No Face-to-Face Contact: Reading an X-ray, interpreting labs, or other non-face-to-face services without an evaluation and management (E/M) visit do not count as a prior visit, meaning the patient remains "new" during their first actual face-to-face encounter.
  • Insurance Changes: Switching insurance carriers does not reset the 3-year clock or qualify an established patient for a new patient billing code.

You can review the official guidelines via the Centers for Medicare & Medicaid Services or the American Academy of Ophthalmology practice management resources.

What are the new CMS rules for 2026?

The Centers for Medicare & Medicaid Services (CMS) introduced major regulatory changes for 2026 across physician reimbursement, Medicare Advantage, marketing, and interoperability.

Physician Fee Schedule & Reimbursements

  • Conversion Factor Adjustments: The 2026 Medicare Physician Fee Schedule conversion factor increased, resulting in a boost of about 3.26% for non-alternative payment models and 3.77% for qualified alternative payment models (APMs).
  • Site-Neutral Shifting: CMS updated practice expense methodologies to redistribute payments, lowering the share for facility-based care (like hospitals) while increasing the share for office-based and independent practices.
  • Care Management Boosts: Base reimbursement rates for chronic care management, annual wellness visits, and transitional care management saw notable dollar increases per code.

Medicare Advantage & Part D Rules

  • Reopening Restrictions: CMS restricted health plans from reopening approved inpatient admissions except in cases of obvious error or fraud.
  • Inflation Reduction Act (IRA) Integration: The rules codify zero-cost adult vaccines and capped insulin cost sharing, along with automated election renewals for the Medicare Prescription Payment Plan.
  • Marketing Relaxations: Effective late 2026, CMS eliminated the 48-hour cool-off period for agent interactions (retaining the signed scope of appointment) and removed the mandatory 12-hour gap between educational and sales events in the same room. Call recording retention for sales was shortened from 10 years to 6 years.

Interoperability & Prior Authorization

  • Electronic Prior Authorization for Drugs: CMS pushed forward new standards requiring impacted payers to integrate electronic prior authorization capabilities and shorten decision timeframes.
  • Access Model: A new 10-year CMS Access model launched in July 2026 to promote outcome-based reimbursements over traditional fee-for-service billing for chronic care management.

What is the Medicare 3-day hospital rule?

The Medicare 3-day rule (also called the 3-midnight rule) requires a patient to have an official inpatient hospital stay of at least three consecutive midnights before Medicare will cover a stay in a skilled nursing facility (SNF).

How the Rule Works

  • Official Status: You must be formally admitted to the hospital as an inpatient. Time spent in the emergency room or under outpatient "observation" status does not count, even if you stay overnight.
  • Counting Midnights: Medicare counts days by midnights. Each midnight you spend in the hospital as an admitted inpatient counts as one day.
  • Exclusions: The day you are discharged from the hospital does not count toward the three-day total.

Why It Matters

If you do not meet the 3-day inpatient requirement, Original Medicare will not pay for your rehabilitation or care in a skilled nursing facility. You would have to pay for those costs yourself.

Exceptions and Waivers

  • Medicare Advantage: Some Medicare Advantage plans do not require the 3-day stay and may cover SNF care without it.
  • Accountable Care Organizations (ACOs): If your doctor belongs to certain approved ACOs, a waiver might apply.
  • Special Models: CMS has demonstration models (such as the Transforming Episode Accountability Model) that waive the rule for specific procedures or patient groups.