Ophthalmology and Optometry Coding Alert

Question: Should I report a consult for an established patient (whom we last saw two years ago) if a new ophthalmologist in our office sees him? This is a new episode of the same problem the patient had earlier.


Arizona Subscriber

Answer: Although standard outpatient visits distinguish between new (99201-99205) and established (99211-99215) patients, office consults (99241-99245) require no such distinction. Consultation codes apply to both new and established patients.

You may report a consult if you meet the minimum consultation requirements: a request for your physician's opinion from the physician who sent the patient for the consult, a review of the patient's condition (your exam), and a written report (from your office to the requesting physician) that describes your findings, diagnoses, treatment recommendations and other relevant information. If the visit does not meet these three requirements, you cannot report a consultation code.

If you don't meet the consult requirements, you should instead select an appropriate-level established patient E/M visit (99211-99215) or established patient eye exam code (92012-92014).

CPT defines a "new" patient as someone whom your practice has not seen within the past three-year period. Because another physician in your practice saw the patient two years ago, CPT considers the patient an "established" patient, which means you should not report a new patient service code.

Remember: All physicians within the same practice (that is, all physicians of the same specialty who share the same group provider number) are "interchangeable" from a coding and billing standpoint.
 
This means that if one ophthalmologist provides an initial new patient office visit (99201-99205)--or provides a consultation and then assumes care--and another ophthalmologist from the same practice provides the follow-up visit, the second physician should report an established patient office visit code (99211-99215) instead of using the new patient codes.