Ophthalmology and Optometry Coding Alert

Question: We have a new ophthalmologist in our group whose patients from his previous group followed him to our group. Some of the staff argues that we should code these patients' first visits in our practice as new patient visits. Some believe we should report them as established. What is the correct way of coding for these first visits to our practice for this new ophthalmologist?

California Subscriber

Answer: The chief factor in determining whether a patient is new or established is always time. You must decide whether your physician has seen the patient in the past, and if he has, how long ago. These guidelines also apply to a new ophthalmologist in an established practice.

How it works: If the new ophthalmologist has provided a face-to-face professional service to a patient elsewhere, such as in a hospital or other practice, within the last 36 months, the patient is an established patient even if this is his first visit to your practice.

Rule: To determine a patient's status, use CPT's established patient definition: "An established patient is one who 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."

If your physician has seen the patient for a professional service in the past three years, you'll report any subsequent visits as established patient E/M codes.

Remember: Professional services that do not involve a face-to-face encounter, such as reviewing laboratory tests without seeing the patient, do not count toward this rule.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, con-sulting manager for Pershing, Yoakley and Associates in Clearwater, Fla.