Optometry Coding & Billing Alert

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

California Subscriber

Answer: The chief factors to consider when determining whether a patient is new or established are always time and doctor. You must decide whether your OD has seen the patient in the past, and if he has, how long ago. These guidelines also apply to a new OD in your practice.

How it works: If the new physician in your clinic has provided professional services 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 optometry 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 billed the patient for a professional service in the past three years, you-ll report any subsequent visits with established patient E/M codes (such as 99211-99215, Office or other outpatient visit for the E/M of an established patient ...).

Remember: Professional services that do not involve a face-to-face encounter, such as an x-ray or laboratory tests, do not count toward this rule. The services involved must include a face-to-face service and encounter.

-- Answers to You Be the Expert, Reader Questions and Building a Better Business reviewed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.