B16
'New patient' qualifications were not met
What This Code Means
A new-patient E/M code was billed, but the patient doesn’t meet the payer’s definition of a new patient (e.g. seen within the last 3 years).
Common Causes
- Patient was actually seen by the same provider/group within the payer's look-back window
- Wrong new-vs-established E/M code selected
How to Resolve or Appeal
- Verify the patient's visit history with this provider/group
- Correct to an established-patient code and resubmit if applicable
Educational reference only — not medical or legal advice. Always confirm code usage and appeal rights with the specific payer.