Ophthalmology and Optometry Coding Alert

Use CPT 99201 -99205 if Patient Switches to Your Office

Question: When my ophthalmologist covers for another local private-practice ophthalmologist, I code the office visits as established patient E/M services. If, a couple of weeks later, a patient decides to switch to my ophthalmologist permanently, should I report a new or an established patient office visit? This visit will require all necessary new patient paperwork.

Tennessee Subscriber

Answer: You should report a new patient office visit code (99201-99205) for your ophthalmologist's E/M service.

As a covering physician, your ophthalmologist temporarily replaces the patient's regular physician, and bills the type of care the regular physician would have reported. As in your example, the patient was established, so it is correct to report an established service to the insurer. If the patient then comes to your practice to specifically see your physician, the patient would be new to the practice and you could use a new patient office visit code (99201-99205, Office visit for the evaluation and management of a new patient ...).

But when the same patient comes to your office to establish a relationship, you have no paperwork regarding the patient, and your records don't indicate that your physician provided any professional services to the patient in the past three years. Because the visit meets CPT's definition of a new patient, you should assign the appropriate-level new patient office visit code.