What is considered an established patient?

• A. Patient who has received professional services from the physician/qualified health care professional or same group practice, within the past three years
• B. A patient who has never seen the clinician
• C. A patient who visits annually for checkups only
• D. A patient with first visit today

Answer: (A)

An established patient is someone who has had a prior professional encounter with the clinician or with another clinician in the same group within a recent time frame, typically the past three years. This prior relationship means the visit is billed as an established-patient encounter rather than a new-patient one, and it guides the level of history, exam, and medical-decision-making documentation required, as well as the appropriate CPT codes.

Why the correct statement fits: it describes a patient who has received professional services from the physician or the same group practice within the past three years, establishing that ongoing relationship. That ongoing relationship is the defining feature of being established, as opposed to a first-time visit.

Why the other scenarios don’t define established status as clearly: a patient who has never seen the clinician is a new patient, since there’s no prior relationship. A patient who visits annually for checkups could be established if there was a prior encounter within the relevant window, but the situation described doesn’t specify that prior contact, so it doesn’t by itself confirm established status. A patient with a first visit today clearly has no prior relationship yet and is thus not established.