PR-B16: New Patient Qualifications Not Met

What Does PR-B16 Mean?

When paired with Group Code PR, the patient was charged the higher new patient rate but only the established patient rate is covered, with the difference being the patient's responsibility. Recode to the established patient rate to prevent incorrect patient billing.

CARC B16 indicates the payer denied the new patient E/M code because the patient does not meet the qualification for new patient status. Per CMS guidelines, a new patient is one who has not received professional services from the same physician or a physician of the same specialty in the same group practice within the previous 3 years.

The most common cause is simply using a new patient E/M code (99202-99205) when the patient is established (should use 99211-99215). This happens when scheduling staff assign new patient status without checking the practice's visit history, when the payer's claims data shows a prior visit within 3 years, or when another physician of the same specialty in the same group already saw the patient.

The resolution is straightforward: recode the visit with the appropriate established patient E/M code and resubmit. If the patient genuinely meets new patient criteria (different specialty, different group, or no visit within 3 years), appeal with documentation proving the qualification.

Common Causes

How to Resolve

1. Recode the visit Change to the established patient E/M code and resubmit.
2. Appeal if new patient status is correct If the patient is truly new, appeal with documentation of the 3-year rule.

How to Prevent PR-B16

• Verify new patient status before quoting the visit charge to the patient
• Use correct E/M codes to prevent patient overcharges

Also Filed As

The same CARC B16 may appear with different Group Codes:

Related Denial Codes