Ophthalmology and Optometry Coding Alert

Question: A new ophthalmologist recently joined our practice. A few of her patients from her old practice have now scheduled visits with us so that they can continue to see her. When these folks come in, should we bill them with new patient E/M codes?

Michigan Subscriber
Answer: To answer this question, you first have to keep in mind the CPT basics on defining new and established patients.

CPT uses the timeframe of treatment by a physician as the chief factor considered. You should think of the physicians relationship to the patient first when determining whether you classify a patient as new or established and what codes to use as a consequence.

You need to consider this on a case-by-case basis. If your new ophthalmologist has provided professional services to a patient within the last three calendar years, then the patient is an established patient (for example, 99211-99215) whether this is his first visit to your practice or not.

If your new physician has not provided professional services to a patient within the last three years, then you should use new patient E/M codes (such as 99201-99205).

This guideline for determining new versus established patient status holds true for all of the physicians in your practice (new to the practice or long-timers). The following response in the Federal Register clarifies the definition and how it relates to Medicare reimbursement:

CPT defines a new patient as one who has not received any professional services from the physician within the past 3 years. An established patient is defined as one who has received professional services from the physician within the past 3 years. For Medicare payment purposes, we interpret the term physician in these definitions to include all physicians practicing in the same group and billing with the same billing number. Therefore, in the case of group practices if a patient has been seen by any physician in the group or clinic, within a 3-year period, the patient is considered established. If a physician is on call for or covering for another physician, the patients encounter will be classified as it would have been by the physician who is not available. Thus, a ocum tenens physician who sees a patient on behalf of the patients attending physician may not bill a new patient code unless the attending physician has not seen the patient for any problem within 3 years.
 
Same rules apply for patients who change healthcare plans or carriers. If any of your ophthalmologists have provided treatment within a three-year timeframe, then the patient is categorized as an established patient.

But there are exceptions. Keep in mind that the rules differ for subspecialties. If your practice has subspecialists working there, then you could potentially have a [...]