Ophthalmology and Optometry Coding Alert

Stand your ground when a carrier shoots you down on new patient visits

Watch out: It's time to fight for new patient visits when your patient sees another physician in your group from a different specialty.

The rules: CPT says a new patient hasn't received any services "from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." The Medicare Claims Processing Manual says physicians "in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group" (Chapter 12, section 30.6.5).

So if you work in a multi-specialty practice and your patient sees a physician from a new specialty, you can bill it as a new patient visit.

Use CMS Manual to Back Up Claims

Problem: Some Medicare carriers have started rejecting new patient visits for transfers within a group, says Lisa Linville, CPC, a coder with a Missouri multi-specialty group. "Their interpretation is if a group shares the same tax ID number they also share the same records," and thus shouldn't bill separately, she says. Other payers have followed Medicare's lead.
 
Solution: You should appeal these sorts of denials, says Laura Talbert with Shore Billing & Management in Allen, Md. Cite the language in Medicare's own manual, and point out that two different specialties are involved, and it could be a fairly simple appeal, she says.

"You need to argue with the carrier," agrees Philip Eskew, medical director with St. Vincent Hospital in Indianapolis. "They're hoping you don't push it," but you should send in a photocopy of the CPT rules and claims processing manual if necessary.

Best practice: Keep an eye on your explanations of benefits (EOBs) to see if your claims are being denied or downcoded, he says.

When a physician from a new specialty sees a patient for the first time, he still has to create a new database with a specialty-specific history and physical exam, Eskew says. If the visit isn't a consult, it's definitely a new patient visit, he adds.

Be careful: Some specialties may not count as separate in Medicare's eyes. For example, a retinologist is considered an ophthalmologist under Medicare, while optometry is a separate specialty.

"Ophthalmology is specialty code 18, which includes retinology, and optometry is specialty code 41," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "However, a retinologist is considered a sub-specialist of general ophthalmology, and as such, may support reporting a consultation code when appropriately requested from a general ophthalmologist within the same group. But, it may be more difficult to justify billing a new patient visit for services rendered by both the general ophthalmologist and the retinal specialist within the same group. Be sure your documentation will support medical necessity."

Try this: If the carrier is denying new patient visits for different specialties, try plugging in the doctor's separate provider identification number (PIN) instead of the group practice's ID, Lewis says.