Ophthalmology and Optometry Coding Alert

Question: Can we report a new patient code if a patient stops seeing one ophthalmologist in our group and begins seeing another? CPT says a new patient is one we have not seen in the past three years, but I have also heard that a new patient is one who requires a medical record to be established.

Arkansas Subscriber

Answer: CPT is very clear on this matter: "A new patient (99201-99205) is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient (99211-99215) is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years."

CPT does not base its new or established patient classification on whether your practice has established a medical record for any particular patient.

The fact that another physician in your practice created a medical record is irrelevant to the type of visit you should report. Because another physician at your practice saw the patient within the last three years, you should report a code from the 92012-92014 or 99211-99215 series.

Upside: The consultation range of codes (99241-99245 and 99271-99275) does not have the same requirement. The patient may receive more than one consultation from the same physician or be referred by a member of the group to another member for consultation.