Ophthalmology and Optometry Coding Alert

Question: Our practice performed a visual field test on a patient who was referred to us by another doctor. Our ophthalmologist was not present for the test; a tech performed the test. Should I consider this patient an established patient?

California Subscriber

Answer: No, you should consider the patient "new" until a face-to-face encounter with your ophthalmologist occurs. Since the visual field test does not carry a distinction of "new" or "established," the test would be reported as usual. If the patient returned to the office at a future date, the patient would be considered "new" for purposes of billing an E/M code.

It would not be appropriate to report an E/M service on the day of the visual field testing since no physician saw the patient. Do not make the mistake of reporting 99211 as this code requires the patient to have been previously evaluated by the physician and the physician to document a plan of care requiring follow-up. Although the tech may provide the followup care; the physician must be physically present and immediately available in the office suite. Reporting an E/M service routinely with planned visual field testing is also not appropriate.

The rules for billing E/M services as new or established are as follows:

If the primary physician (or another physician of the same specialty and billing under the same group number) provided a non-face-to-face service for a patient and the patient returned at a later date for a face-to-face service with the physician, you would consider the patient to be "new" when selecting an E/M service code.

According to AMA guidelines, there are additional factors to consider as well: The 3-year rule is a well-established rule for "new" versus "established" patients. That is, if any physician with the same specialty within a given practice sees a patient within a 36- month period, that patient is considered "established." If no further visits occur during a 36 month period following the last visit, the patient would return to new patient status.