Optometry Coding & Billing Alert

Even if the patient has been to your office before, he might be new

Proper billing for various evaluation and management services (such as outpatient visits and rest home services, for example) rests on determining whether a patient is -new- or -established,- as defined by the AMA's guidelines.

To make the -new vs. established- decision easier, CPT 2007 includes a helpful flowchart -- making a foolproof decision only a few questions away.

Keep Applying the 3-Year Rule

If the physician, or any physician of the same specialty billing under a common group number, has never seen a patient before, that patient is automatically categorized as -new.- And if the same physician (or, once again, any physician of the same specialty billing under a common group number) hasn't seen the patient within the past 36 months, you may likewise consider the patient -new- from a billing and coding standpoint.

Example: The optometrist sees a patient in the office at the patient's request (in other words, the service is not a consult). Although the optometrist has seen the patient in the past, the last visit occurred more than four years ago.

In this case, the patient is considered new rather than established. So, you would choose to bill a code from the new patient outpatient services category (99201-99205) rather than the established patient outpatient services category (99211-99215).

If your optometrist has billed the patient for a professional service in the past three years, you-ll bill any subsequent visits as established patient E/M codes (such as 99211-99215), says Beth Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants in Winston-Salem, N.C.

Don't Factor in Location

If the same optometrist or another physician of the same specialty is billing under the same group number and sees the patient at any time within a three-year timeframe, you must consider the patient to be -established,- even if the patient was seen at different locations, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Tip: These guidelines also apply to a new optometrist  and any patients he sees prior to joining your practice. If the new optometrist 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 practice.

Example: A group practice maintains two offices on separate sides of town. A patient sees optometrist -A- for a complaint of eye pain at location -Y.- Six months later, the same patient sees optometrist -B,- in the same group practice and specialty, for a new complaint at location -Z.-

In this case, the patient is established -- even though the encounters took place at separate locations and involved separate providers.

Here's why: Because the optometrists are of the same specialty and are billing under the same group number, the -three-year rule- applies. Had the optometrists been of different specialties -- or if they billed under different provider numbers -- the second optometrist may have been able to report the patient as -new,- as long as she hadn't seen that patient within the previous 36 months.

Master Face-to-Face Matters

As in past years, the -new vs. established- guidelines apply only to face-to-face services. Therefore, if an optometrist (or another optometrist billing under the same group number) provided a non-face-to-face service for a patient, and then provided a face-to-face service within three years of the non-face-to-face service, you should still consider the patient to be -new- when selecting an E/M service code to bill.

Different Specialty May Equal New Patient

When optometrists of different specialties see the same patient within the same 36-month period, the usual -new vs. established- rules do not apply. Specifically, if a optometrist of a different specialty with the same tax ID within a multispecialty practice -- or a subspecialist billing with a unique tax ID number -- sees a patient for the first time, you may consider the patient to be -new- even if he has seen other optometrists within the group practice during the previous three years.

If a subspecialist has a specialist distinction that is different from that of the optometrist who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient per the June 1999 CPT Assistant, says Stacie L. Buck, RHIA, LHRM, president of Health Information Management Associates Inc. in North Palm Beach, Fla.

The difference: The subspecialist must be registered with a unique taxonomy code/number for his subspecialty, and the patient must not have seen any other optometrist who provides services of the same subspecialty for the practice within the last three years.