Summary

A guide to billing for Evaluation and Management (E/M) services for new patients in California, complete with links to the necessary regulatory information and detailed instructions

CCR § 9789.12.11 separately defines and distinguishes:

• new patients, and
• established patients.

New Vs. Established Patient

1. A “new patient” is one who is new to the physician or medical group or an established patient with a new industrial injury or illness. Only one new patient visit is reimbursable  when billing for the same incident, injury or illness.
2. An “established patient” is a patient who has been seen previously for the same incident, injury or illness.

CCR § 9789.12.11 also establishes the required guidelines for Evaluation & Management Services. For Evaluation & Management services, physicians and qualified non-physician practitioners must use either:

• the “1995 Documentation Guidelines for Evaluation & Management Services,”
• or “1997 Documentation Guidelines for Evaluation and Management Services.”

California Code of Regulations (CCR)

§ 9789.12.11 Evaluation and Management: Coding - New Patient; Documentation

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

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