Ophthalmology and Optometry Coding Alert

Even if the patient has been to your office before, he might be 'new'

Proper coding for various E/M services (such as outpatient visits and rest home services, for example) rests on determining whether a patient is "new" or "established," as defined by AMA guidelines. To make the "new vs. established" decision easier, CPT 2007 includes a helpful flow-chart, making a foolproof decision only a few questions away.

Keep Applying the 3-Year Rule

If the physician, or any physician of the same specialty billing under a common group number, has never seen a patient before, that patient is automatically categorized as "new." In addition, if the same physician (or, once again, any physician of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient "new" from a coding standpoint.

Example: The ophthalmologist meets with a patient in the office at the patient's request (in other words, the service is not a consult). Although the ophthalmologist has seen the patient in the past, the last visit occurred more than four years before.
 
In this case, the patient is considered new rather than established. Therefore, you would choose an E/M service code from the new patient outpatient services category (99201-99205) rather than from the established patient outpatient services category (99211-99215).

Subsequent Visits Require E/M Codes

If your physician has billed the patient for a professional service in the past three years, you'll report any subsequent visits as established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

Don't Factor In Location

If the same physician or another physician of the same specialty is billing under the same group number and sees the patient anytime within a three-year timeframe, you must consider the patient to be "established," even if the patient was seen at different locations, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Tip: These guidelines also apply to a new physician and any patients he sees prior to joining your practice. If the new ophthalmologist has provided professional services to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Example: A group practice maintains two offices on separate sides of town. A patient sees ophthalmologist "A" for a complaint of eye pain at location "Y." Six months later, the same patient sees ophthalmologist "B," in the same group practice, for a new complaint at location "Z."

In this case, the patient is established -- even though the encounters took place at separate locations and involved separate ophthalmologists.

Here's why: Because the ophthalmologists are of the same specialty and billing under the same group number, the "three-year rule" applies. Had the ophthalmologists been of different specialties -- or if they billed under different provider numbers -- the second ophthalmologist may have been able to report the patient as "new," as long as she hadn't seen that patient within the previous 36 months.

Master Face-to-Face Matters

As in past years, the "new vs. established" guidelines apply only to face-to-face services. Therefore, if a physician (or another physician billing under the same group number) provided a non-face-to-face service for a patient, and then provided a face-to-face service within  three years, you should still consider the patient to be "new" when selecting an E/M service code.

Example: The ophthalmologist meets with a patient for the first time for a new complaint. Another ophthalmologist in the same practice interpreted some test results for the same patient the previous year, but provided no face-to-face service during the previous three years.

In this case, the ophthalmologist providing the current service may still consider the patient to be new when selecting an initial E/M code because no physician within the group practice provided the patient with a face-to-face service within the past three years.

Different Specialties Can Make the Difference

When physicians of different specialties see the same patient within the same 36-month period, the usual "new vs. established" rules do not apply. Specifically, if a physician of a different specialty -- or a sub-specialist billing with a unique tax I.D. number -- sees a patient for the first time, you may consider the patient to be "new" even if he has been seen by other physicians within the group practice during the previous three years.

If a sub-specialist has a specialist distinction that is different from that of the physician/specialist who provided a previous service to the patient, you may consider the patient receiving professional services from that sub-specialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. in North Palm Beach, Fla.

The difference: The sub-specialist must have and be registered with a unique taxonomy code/number for his subspecialty, and the patient must not have seen any other physician who provides services of the same sub-specialty for the practice within the last three years (see www.wpc-edi.com/codes/taxonomy for a list of all specialties).

Example: An internist in a multiple-specialty practice sees a patient in 2005 for diabetes treatments. In early 2007, the same patient sees the ophthalmologist (a member of the same multi-specialty practice) for an office E/M service regarding a new complaint.

Because the internist and ophthalmologist (who are obviously of different specialties) saw the patient for completely unrelated problems (this is key), you may report the ophthalmologist's initial visit with the patient assigning the new patient codes.