Ophthalmology and Optometry Coding Alert

After 3 years, faces familiar to your ophthalmology practices are new again

If a patient you last saw in 2002 for an eye exam returns to your practice, should you code him as a "new" or "established" patient? What if it wasn't the same doctor who saw him, but another eye doctor in your office?

New Medicare guidelines might make the answers to those questions a little clearer. The Centers for Medicare & Medicaid Services (CMS) tweaked some of the rules for evaluation and management coding in Transmittal 731, dated Oct. 28.

To start, CMS clarified the definition of "new patient" for E/M purposes. Experts say the policy hasn't really changed, but CMS is explaining it differently, and it can provide a useful refresher course.

According to CMS, use a new patient E/M code if none of your physicians have seen the patient face-to-face in the past three years, says Elena Vargas, OCS, coding specialist for Rashid and Rice Eye Associates in San Antonio.

In other words, if one of your physicians interpreted a patient's test results or did some other non-face-to-face service in the past three years, you can still consider that person a new patient the next time she comes into the office, according to consultant Devona Slater with Auditing for Compliance & Education in Leawood, Kan.

Document That Problems Were Unrelated

"Many times, our physicians don't realize they can use a new patient code if they haven't seen the patient in 36 months," says Robyn Brooks with Lee-Brooks Consulting in Chicago.

Also, CMS says it won't pay for any E/M services on the same day by physicians in the same practice and same specialty--unless you document that the visits were for unrelated problems.

Sometimes carriers won't pay for same-day E/Ms even when they're for unrelated problems, but CMS is telling the carriers to pay for same-day, different-provider visits when appropriate.

Check it out: To download the transmittal, visit www.cms.hhs.gov/manuals/pm_trans/R731CP.pdf.