Optometry Coding & Billing Alert

New rules place emphasis on subspecialties.

It's an age-old debate --when an established patient presents to your practice to see a new physician, should you report a new patient office visit code? CPT® 2012 attempts to clarify when that's possible with a revision to the "New and Established Patient" section of the CPT® manual.

The rules: Currently, CPT® indicates that a "new patient" refers to a patient who has not received any professional services, such as an E/M or other face-to-face service from the physician or physician group practice -- within the same physician specialty -- within the past three years.

Clarification: CPT® 2012 takes that definition a step further, now stating, "A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." The portions of the description that are new for 2012 are underlined.

What this means to you: If your practice employs various subspecialists, CPT® now makes it clear that claims for patients who see different doctors with different subspecialties can be billed using a new patient code (such as 99201-99205). Peter A. Hollmann, MD, chair of the CPT® Editorial Panel, offered the following example during the CPT® 2012 Annual Symposium in Chicago on Nov. 16:

Example: A cardiology practice employs a general cardiologist and an electrophysiologist (EP), and both physicians are classified as these separate specialties with their payers. The cardiologist refers a patient to the EP for consideration of an implantable cardiodefibrillator. In this situation, the visit with the EP should qualify as a new patient visit, assuming the payer accepts these CPT® rules.