Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist said that if an established patient comes in for workers' comp, we code it as a new patient visit for the first workers' comp visit. That doesn't make sense to me. Who is right?

Michigan Subscriber

Answer: You are correct: Report this as an established patient encounter. You need to explain to your provider that the type of insurance coverage for a visit, including workers' compensation, does not affect whether you should bill a patient as new or established. An established patient -- one who your provider or another provider in the same practice and same specialty has seen within the past three years -- is an established patient, regardless of insurance. In this case, if the patient is already established with your practice, you should bill the appropriate level E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) to the workers' compensation insurance.

Note: If your ophthalmologist is performing a consultation -- 99241-99245 (Office consultation for a new or established patient ...) -- then you would bill the consultation codes (including those performed in the hospital [99251-99255]) regardless of whether the patient is new or established. The consultation codes do not differentiate between new and established.

Best bet: Check your state's WC regulations before billing any WC claim. Each workers' compensation jurisdiction may set its own rules and regulations.