CurrentColorado Rocky Mountain Health PlansPolicy 2025R9024B

CMS 1500 — New Patient E/M and Initial Visit Reimbursement Policy

Governs appropriate submission and reimbursement of New Patient evaluation and management (E/M) codes and Initial Visit HCPCS codes on CMS 1500 forms for UnitedHealthcare Medicare Advantage plans and applicable providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 — New Patient E/M and Initial Visit Reimbursement Policy

Policy CodePolicy 2025R9024B

Change TypeMinor / administrative (no material changes)

Effective Date

Next Review Date

Key ActionVerify New Patient status using a 3-year lookback to the same specialty and group before submitting New Patient E/M or Initial Visit codes on the CMS 1500 form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS 1500form this policy applies to

3 yearslookback period

NP, CNS, CNM, PAeligible non-physician practitioners

policy list updatedversion activity

Coverage criteria for New Patient and Initial Visit

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New Patient and Initial Visit Reimbursement Criteria

Covered when the following criteria and definitions are met:

New Patient E/M code reimbursed only when the New Patient definition is met (no professional E/M or other face-to-face service from the same specialty in the same group within the previous 3 years).

For determination of New Patient status, an interpretation or other professional component billed in the 3-year lookback (e.g., lab interpretation, reading an x-ray or EKG) without an E/M or other face-to-face service does NOT negate New Patient status; the patient remains a New Patient for an Initial Visit.

If a physician is on-call or covering and bills under the same Federal Tax Identification number, the encounter is classified as it would have been by the unavailable physician and is not considered a New Patient solely because a covering physician provided the visit.

UnitedHealthcare Medicare Advantage will not pay two E/M office visits billed by physicians of the same specialty from the same group for the same beneficiary on the same day unless the documentation shows the visits were for unrelated problems that could not be provided during the same encounter; physicians in the same group and specialty should select a single representative level of service for combined visits.

UnitedHealthcare Medicare Advantage will reimburse E/M services for non-physician practitioners (NP, CNS, CNM, and PA) when Medicare permits billing; services must be medically necessary, within scope of practice, and comply with applicable state rules and billing/supervision requirements.

Initial Visit HCPCS codes will be reimbursed only if the patient has not previously been seen for an Initial or Subsequent Visit.

Provider documentation must support the level of service reported; services must be reasonable and necessary and the volume of documentation alone should not determine level selection.

E/M and Initial Visit codes and lookback

E/M and Initial Visit codesCPT

New Patient E/M codes	E/M codes for new patients as listed in attachment referenced by policy
Initial Visit HCPCS	Initial Visit HCPCS codes applicable to the policy

New patient lookback

Lookback period3 years without a professional face-to-face service (E/M or other) from the same specialty in the same group

Scope of services countedIncludes E/M services and other face-to-face services such as surgical procedures; interpretation-only professional components (e.g., lab, x-ray, EKG) do not negate New Patient status if no face-to-face E/M occurred

On-call/covering physician ruleEncounters billed by on-call or covering physicians under the same Federal Tax Identification number are classified as if seen by the unavailable physician and do not create New Patient status

Provider actions and policy updates

Prior Authorization

Prior authorization / policy updates

UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with changes in CMS policy and other national standard coding guidelines by publishing a new version of the reimbursement policy on this website. Providers are responsible for submission of accurate claims and should ensure they bill using the code or codes that correctly describe the services provided. UnitedHealthcare Medicare Advantage encourages physicians and other health care professionals to keep current with CMS policy changes and billing requirements by referring to the CMS or local carrier website regularly and signing up for regular distributions for policy or regulatory changes. Note: UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; providers should verify prior authorization requirements through the member’s benefit documents or the payer’s authorization resources.

Applies to UnitedHealthcare Medicare Advantage Plans and is intended as a general resource; it does not replace benefit documents or provider contracts.
Policy may be modified at any time to comply with CMS or national coding guideline changes — check the payer website for the latest version.
Providers must submit accurate claims using appropriate CPT/CMS coding and may need to monitor CMS/local carrier websites for updates.
UnitedHealthcare Medicare Advantage reimbursement policies do not include prior authorization notations — verify prior auth requirements through member benefit coverage or payer authorization channels.

Definitions

Same Specialty Physician

DefinitionPhysician and/or Other Qualified Health Care Professional of the same group and same specialty reporting the same Federal Tax Identification number

Implication for billingMembers of the same specialty within the same group (same TIN) are treated as the same provider group for New Patient determination

Related conceptSame Group Physicians are defined as all physicians/qualified health care professionals reporting the same Federal Tax Identification number

New Patient

DefinitionPatient who has not received any professional services (E/M or other face-to-face) from the physician or physician group practice (same specialty) within the previous 3 years

Effect on reimbursementA New Patient E/M code will be reimbursed only when the New Patient definition is met

Exception — professional component onlyBilling of a professional component (e.g., lab interpretation) without a face-to-face E/M does not remove New Patient status

Initial Visit

DefinitionAn Initial Visit is the first patient encounter for a specific purpose

Subsequent visit distinctionA Subsequent Visit is any encounter after the Initial Visit for that specific purpose

Use in claimsInitial Visit HCPCS codes apply when no prior Initial or Subsequent Visit for that purpose has occurred

Same Individual Physician

DefinitionIndividual rendering services reporting the same National Provider Identifier (NPI)

Billing implicationServices billed under the same NPI are attributed to the same individual provider for New Patient and visit determinations

Distinct from groupDifferentiate from 'Same Group' which is based on shared Federal Tax Identification number