Ophthalmology and Optometry Coding Alert

Question: Our office saw a patient six months ago for a certain condition, and sent the patient back to his primary care provider for further treatment. The same patient was recently referred back to us for a different condition. Should we bill that patient as new, since he's coming back for a different reason?

New Mexico Subscriber

Answer: This patient should be considered "established" for many reasons.

If your physician sees a patient any time within a 36-month period, that patient is considered established, regardless of the reasons for the visits. This is the AMA's "three-year rule." You should go by this rule even if another physician in your practice sees the patient, as long as it's within the 36 months. Location is not a factor either, in the event your practice has more than one location.

Why: This rule applies as long as all the physicians in your group bill under the same group number.

Caution: The rules change a bit if you are operating in a multi-specialty practice. If a physician of a different specialty sees a patient for the first time, you may consider the patient to be "new" even if he has seen other physicians in other specialties within the group practice during the previous three years. But if the patient has already seen a physician of the same specialty within the multi-specialty physician practice, then the patient is considered "established" for reporting purposes.