What is the definition of an established patient?

An established patient is defined as one who has received professional services from the provider or a provider of the same specialty in the same group within the last three years. This definition is essential for understanding patient classification in billing and coding, as it affects how services are billed and the level of care required for reimbursement.

When determining if a patient is considered established, the time frame is crucial. A patient who has not seen the provider within the last three years would be categorized as a new patient, which often involves different billing practices and may require additional paperwork and coding. This distinction is significant in maintaining accurate medical records and ensuring proper reimbursement.

Other definitions that specify different time frames, like one year or two years, do not align with the standard established by the American Medical Association and other healthcare billing regulations, which uniformly recognize the three-year timeline. Therefore, understanding the specific criteria that categorize a patient as established is fundamental in the context of physician office billing practices.