Ophthalmology and Optometry Coding Alert

Question: We recently had a patient switch from an HMO to direct Medicare coverage. Our physician wants us to bill the patient's next visit with a new patient code. Would the patient really be considered "new" just because his insurance has changed?

Utah Subscriber

Answer: You are right to question just how "new" the patient would be considered by Medicare - especially in the event of an audit. When you are deliberating over the status of a patient, ask yourself this: Has the patient ever received any professional services - face-to-face services rendered by a physician and reported by a specific CPT code(s) - from your physician or another physician of same specialty who belongs to the same group practice, within the past three years?

If the answer is yes, the patient is never considered "new," according to CPT's E/M Services Guidelines. Therefore, you can only use the E/M codes for established patients, 99211-99215, or eye codes, 92012-92014. Remember, you are classifying the patient, not the patient's third-party carrier.