Publication Date: 

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has updated our definition of “new” and “established” patients within our medical policies to align with guidelines from the Centers for Medicare and Medicaid Services (CMS). This policy change will go into effect on March 9, 2021, and was made publicly available on our Medical Policy Updates site on December 31, 2020.   


“New” vs. “Established” Patients 

If a member has received professional Evaluation and Management (E/M) services or other face-to-face services from a physician or group practice (same specialty) within the previous three years, that member is no longer considered a “new” patient when billing E/M codes. Instead, this member is now an “established” patient.  

Prior to this update, the three year look back period only considered E/M codes.  When a claim is received reporting a new patient E/M service that does not meet this updated definition, the new patient evaluation and management service code will be replaced with the equivalent established patient evaluation and management code if one is available.   


Impacts to Providers 

  • These changes apply to the following groups: Administrative Services Only (ASO), fully insured groups, fully insured individuals under 65, IPP Host, and the State Health Plan (SHP). 
  • By March 9, 2021, providers will need to ensure that they are correctly coding these services. If filed inappropriately, our system will change the filed code if an equivalent code is available.