CurrentUnitedHealthcarePolicy 2026R0004B

New Patient and Initial Visit E/M Reimbursement

Defines UnitedHealthcare's reimbursement rules for New Patient evaluation and management (E/M) codes and Initial Visit HCPCS codes billed on CMS-1500 (or electronic equivalent) for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyNew Patient and Initial Visit E/M Reimbursement

Policy CodePolicy 2026R0004B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit New Patient E/M codes only when the patient has not received professional services from the same specialty reporting under the same TIN within the past 3 years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-yeartimeframe to determine New Patient status

CMS-1500form(s) covered

Commercial & Exchangeproduct applicability

Same Specialty/Same TINgroup practice rule

Coverage Criteria for New Patient and Initial Visit E/M

UnitedHealthcare follows CMS definitions for New Patient and Initial Visit coding. Reimbursement for New Patient E/M and Initial Visit HCPCS codes will be based on the CMS three-year and initial-visit rules described below.

ALL of the following

New Patient reimbursement: A New Patient is a patient who has not received any professional services (E/M or other face-to-face service, e.g., surgical procedure) from the physician or another physician of the same specialty in the same group practice reporting the same Federal Tax Identification Number within the past three years.
Same Specialty Physician = physician or other qualified health care professional of the same group and same specialty reporting the same TIN.
UnitedHealthcare will reimburse a New Patient E/M code only when the CMS definition above is met.
If a provider is on-call or covering for another physician and billing under the same TIN, the encounter is classified as it would have been by the unavailable physician; the patient is not considered a New Patient solely because the visit was with the on‑call physician.

Initial Visit reimbursement

Policy Summary

PayerUnitedHealthcare

PolicyNew Patient and Initial Visit E/M Reimbursement

Policy CodePolicy 2026R0004B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit New Patient E/M codes only when the patient has not received professional services from the same specialty reporting under the same TIN within the past 3 years.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Special situations / common questions

Emergency department services: For E/M coding, CPT makes no distinction between new and established patients in the emergency department; E/M services there may be reported for any new or established patient who presents for treatment.
Follow CPT/ED guidance when reporting ED E/M services.
Claims billed by nurse practitioners or physician assistants: Credentials (e.g., NP, PA) are not considered specialty designations. If a current claim for a New Patient E/M is submitted by an NP/PA under a TIN and there is prior history of an NP/PA (same TIN) providing services to that patient within three years, the New Patient code will not be reimbursed.
Provider should review documentation and, if appropriate, resubmit with the correct established E/M code.
Subspecialty vs specialty: A visit by a physician of a different subspecialty but the same broader specialty under the same TIN is treated as the same specialty for New Patient determinations; prior services by any physician of the same specialty within the group and TIN within three years will preclude New Patient reimbursement.
UnitedHealthcare follows CMS policy on specialty determinations.

Coding Guidance and Examples

Examples from New Patient Codes tableCPT

99202	New patient E/M code (example mapping listed)
99383	New patient preventive code (examples listed)
G0438	Initial annual wellness visit mapping example

Examples from New Patient Codes table (additional mapping entries present in source)CPT

99203	Mapped result shown in table (e.g., 99202, 92004 = 99203)
99204	Mapped result shown in table (e.g., 99202, 98000 = 99204)
99205	Mapped result shown in table (e.g., 99202, 98001 = 99205)

New patient definition window

Lookback window3-year lookback: No professional services from the same specialty reporting under the same TIN within the past three years

Scope of services consideredProfessional services include E/M services or other face-to-face services (e.g., surgical procedures)

Group practice determinationSame Specialty/Same TIN (physicians or other qualified health care professionals of the same group reporting the same Federal Tax Identification number)

Billing and Submission Requirements

Billing Rule

Billing requirements for New Patient and Initial Visit — Ensure New Patient E/M codes are submitted only when patient has not received professional services from same specialty within same TIN within past 3 years

Submit New Patient E/M codes only when the patient meets the CMS definition of a New Patient: the patient has not received any professional services (E/M or other face‑to‑face services such as surgical procedures) from the physician or another physician of the same specialty in the same group practice reporting under the same Federal Tax Identification Number (TIN) within the past three years. For Initial Visit HCPCS codes, submit only when the Same Specialty Physician has not previously reported the same Initial Visit code or any HCPCS code described as a Subsequent Visit for that patient. When a physician is on‑call or covering and bills under the same TIN, 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.

Affected codes: New Patient E/M CPT codes and Initial Visit HCPCS codes
Same‑specialty and same‑TIN rule applies (3‑year lookback)
On‑call/covering physicians billing under same TIN do not create a New Patient status

Key Definitions

New Patient — definition relative to same specialty/same TIN

DefinitionNew Patient: a patient who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice (same TIN), within the past three years

What counts as professional servicesIncludes E/M services or other face-to-face services (for example, surgical procedures)

On-call/covering physiciansEncounters with on-call or covering physicians billing under the same TIN are classified as they would have been by the unavailable physician and are not automatically New Patient encounters

Initial Visit — definition

DefinitionInitial Visit: the first patient encounter for a specific purpose (e.g., first E/M visit, first annual wellness visit, first visit to address a specified condition)

Reimbursement conditionUnitedHealthcare will reimburse an Initial Visit HCPCS code only when the Same Specialty Physician has not previously reported the same Initial Visit HCPCS code or a HCPCS code described as a Subsequent Visit for the same patient

Relationship to Subsequent VisitAn Initial Visit precedes any Subsequent Visit, which is any encounter occurring after the initial patient encounter for that specific purpose

Same Specialty Physician — definition

DefinitionSame Specialty Physician: physicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number

IncludesPhysicians and other qualified health care professionals who independently report professional services within their scope of practice

Use for coverage determinationUsed to determine New Patient status and applicability of Initial Visit reimbursement rules (same specialty + same TIN)

Subsequent Visit — definition

DefinitionSubsequent Visit: any encounter that occurs after the initial patient encounter for a specific purpose

Implication for Initial Visit codingReporting a Subsequent Visit by the Same Specialty Physician for the same patient precludes reimbursement of an Initial Visit HCPCS code for that same purpose

SequenceInitial Visit (first encounter for purpose) → Subsequent Visit (any later encounters for that purpose)