Ophthalmology and Optometry Coding Alert

Question: We were recently audited and an established patient visit was marked as incorrect because the auditor considered the patient to be new. We had seen the patient within the last three years, so can you advise what could have gone wrong?

Codify Subscriber

Answer: A close reading of CPT^®’s new and established patient guidelines reveals much more than the simple definition that a new patient is one that has not received services from your practice in three years prior to seeing your provider. CPT^® also requires that:

1. The services need to be professional. “Professional” means services following the CPT^® definition of being performed by a physician or other qualified healthcare professional.

2. The services need to be face-to-face. CMS has determined that services such as diagnostic tests or radiologic interpretations do not affect a patient’s status unless they are accompanied by an E/M or other face-to-face service.

3. The services need to be in the same specialty or subspecialty. This part of the definition can be significant for large practices that may employ subspecialists, as patients that may be regarded as established in one specialty may be classified as new when they are seen for the first time by a specialist in a different field.

It’s unclear which one of these three criteria your office may have misinterpreted, but if, for instance, the patient merely bought glasses from your office and never saw a practitioner face-to-face in the last three years, that patient would likely be considered “new” rather than “established.”