Optometry Coding & Billing Alert

Question: When we use code 92004 (Ophthalmological services; comprehensive, new patient) for a complete exam (new patient), how much time must pass without seeing this patient before we can bill for a new patient exam again?

Florida Subscriber

Answer: Refer to your CPT manual for new patient definitions. The 2003 CPT manual defines a new patient as one who has not received any professional services from the physician or from any another physician of the same specialty belonging to the same group practice within the past three years. This also means that if you're in a group practice in which a patient may not be seen by the same physician for each visit, that person is not considered to be a new patient.
 
However, you should also be aware of how this handling of "new" comes into play when a physician
purchases a practice. Often, when the practice that is purchased includes the medical records of existing patients, the physician is unsure whether his initial visit is considered new. This depends on how the new owner of the practice came into the group.
 
If the new physician became a member of the group practice, saw established patients of that practice, and then purchased the practice and retained the group number, he could not bill a new patient service until three years had passed.
 
Alternatively, if the physician purchased the practice and established a new provider number with Medicare, each patient the physician saw could be considered a new patient, even if the old records were referenced when seeing the patient.