Ophthalmology and Optometry Coding Alert

Reader Questions:

Draw On These Details To Decide New vs. Established E/M

Published on Mon Sep 25, 2023

Question: If a patient sees one ophthalmologist in our group practice, then one year later sees a different eye care provider in the same practice, should we bill the subsequent encounter as a new or established patient visit?

Alaska Subscriber

Answer: It depends on the second provider’s specialty. CPT^®defines a new patient as “one who has not received any professional services from the physician … or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

The Centers for Medicare & Medicaid Services (CMS), on the other hand, defines a new patient as one who has not received any professional services from the physician or physician group practice (same specialty) within the previous three years. CMS makes no reference to subspecialties, though.

Bottom line: Once a patient is established with one of the ophthalmologists in your practice, they are considered established with all other ophthalmologists in the practice. If the second provider is an optometrist, then they would be considered a new patient, as those are two distinct specialties. Medicare does not make a distinction by subspecialty, so you would not bill the patient as new again when they see a retina, glaucoma, or plastics specialist. Per CPT^®, however, a patient could be considered new to your practice as they moved from one subspecialist to another. Most payers apply the CMS definition and process claims accordingly.

Taxonomy: The National Uniform Claim Committee (NUCC) provides a taxonomy code set that lists unique 10-character codes that classify a physician’s provider grouping (DO, MD), classification (specialty, such as ophthalmology), and subspecialty.

Key: Optometry and ophthalmology are different specialties.