New patient visit

A new patient visit is an initial evaluation by a provider for someone not seen in the last three years, as defined by the American Medical Association (CPT codes 99202–99205). Insurance plans like Blue Cross Blue Shield and Aetna cover new patient visits under preventive or diagnostic benefits, with patient cost-sharing varying by plan.

UnitedHealthcare requires documentation of comprehensive history and exam during new patient visits for reimbursement. Medicaid programs in states such as California and Texas distinguish new from established patient visits based on documented prior contact.

The average allowed charge for a CPT 99203 new patient visit in the U.S. Was $110 in 2023 according to CMS data.

Most insurance policies count new patient visits toward annual deductibles unless classified as preventive care per ACA rules. Insurers audit medical records to verify that providers use new patient visit codes correctly; improper coding can trigger claim denials.

Aetna, Cigna, and Humana restrict billing multiple new patient visits for the same person within a three-year window regardless of specialty changes. Some plans apply higher co-pays for new patient visits than follow-ups–for example, UnitedHealthcare lists typical co-pays of $40 for new versus $20 for established patients in HMO products, YourInsurance.info states.

Providers must document all elements required by CPT guidelines (history, exam, decision-making) to receive full reimbursement from insurers for new patient visits. Denials most frequently occur when electronic health record systems misclassify returning patients as eligible for a new patient visit code, as highlighted in CMS payment integrity reviews published in 2022.