Ophthalmology and Optometry Coding Alert

You can collect more for new patients — but check these guidelines first.

What’s the difference between a new patient evaluation and management (E/M) and an established patient service? About a 20 percent increase in pay, according to the 2024 Medicare Physician Fee Schedule.

But while it’s always beneficial to bring in more reimbursement, you can only do so when warranted and justified. When it comes to E/M services, you can’t collect for a new patient visit with 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) unless the patient is truly new based on CPT® and CMS rules.

Check out three essential pieces of information you must know if you’re trying to differentiate new vs. established patients.

1. The 3-Year Rule Applies to Face-to-Face Services

CMS defines a new patient as someone who hasn’t received “professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.”

And while the “three year rule” is widely known, many people interpret it to believe the provider must have had an E/M visit with the patient within the past three years. However, as the definition clarifies, it applies to any professional service from that physician or another physician of the same specialty at that practice within the past three years.

Face-to-face visits wouldn’t typically include the physician’s work interpreting lab results or radiology scans. But they may include quite a few more services than most practices would think. For instance, the following might count as face-to-face services:

• Dr. Smith consults with a patient in the hospital two years before Dr. Smith sees the same patient in the office for an E/M service.
• Dr. Jones sees a patient for a COPD assessment at a practice in Southern Illinois in 2023. Dr. Jones sees that same patient for a COPD assessment at their new practice working in Chicago in 2024.
• Dr. Cooper sees a patient in 2022 for an allergy test and then retires from the practice. In 2023, Dr. Johnson replaces Dr. Cooper as the new allergist at the practice, and sees the same patient for an allergy shot visit.

All of these would be considered established patients, which means you’d bill them with the appropriate established patient code from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).

2. Patient Follows Doctor? It’s Probably Established

Like everyone else, physicians may not stay with the same employer for a lifetime. And when they leave one practice and go to another, patients may follow them so they can keep seeing the same doctor for their treatment.

But when that happens, it’s not correct to automatically assume the patient is “new” from a coding standpoint. Even though the front office staff may have never seen the patient before, if the doctor has seen the patient in the last three years, they’re still established.

As the definition says, a new patient is one who hasn’t received professional services “from the physician or physician group practice” in the prior three years. So, whether the patient has seen a doctor at this practice in the last three years or they’ve seen the physician at a different practice previously, they’re still considered an established patient.

In addition, new diagnoses don’t make a patient new. If the doctor sees the patient in 2022 for skin cancer and again in 2024 for eczema, the patient is still an established patient at the 2024 visit.

3. Multiple Locations Won’t Get You Around the 3-Year Rule

Practices with several offices in different regions often get confused about how the new and established patient rules apply to them.

For instance, suppose a cardiologist sees a patient at ABC Medical Associates’ Orlando office in 2023. Then, in 2024, a cardiologist sees the same patient at ABC Medical Associates’ Tallahassee office. Even though the patient saw a cardiologist in two separate cities, the visits still took place through the same entity — ABC Medical Associates. Since the patient, the practice, and the specialty were all the same, and the visits took place within the same three-year period, the patient would be considered established.

However, one key exception is if the physicians are of different specialties. If the patient sees a cardiologist at ABC Medical Associates in 2023 for Wolff-Parkinson-White syndrome but then sees a pulmonologist at ABC Medical Associates in 2024 for asthma, the patient would be considered new when they see the pulmonologist, since they haven’t previously seen a pulmonologist at that practice.

Why This Matters

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) considers it upcoding if you report a new patient visit when the patient is actually established.

In black and white: “An example of upcoding is an instance when you provide a follow-up office visit … but bill using a higher level E&M code as if you had provided a comprehensive new patient office visit or an initial inpatient consultation,” the OIG says in its “Physician Relationships With Payers” document.

If a practice is found guilty of upcoding, they’ll have to pay back the money they collected for the claims submitted in error. If they’re found to be fraudulently upcoding, they may face more serious sanctions, such as civil fines and criminal charges. That’s why it’s essential to confirm that a patient is truly new before reporting a new patient office visit code.

Torrey Kim, Contributing Writer, Raleigh, N.C.