Optometry Coding & Billing Alert

Question: An optometrist in our practice said that if an established patient comes in for workers- comp, we code it as a new patient visit for the first workers- comp visit. That doesn't make sense to me. Who is right?

Michigan Subscriber

Answer: You are correct: Report this as an established patient encounter. You need to explain to your provider that the type of insurance coverage for a visit, including workers- compensation, does not affect whether you should bill a patient as new or established. An established patient -- one who your provider or another provider in the same practice and same specialty has seen within the past three years -- is an established patient, regardless of insurance. In this case, if the patient is already established with your practice, you should bill the appropriate level E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) to the workers- compensation insurance.

Keep in mind: You can report a prolonged services code (+99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient evaluation and management service]; and +99355, ... each additional 30 minutes [list separately in addition to code for prolonged physician service]) in addition to the office visit code if the optometrist has to spend additional time evaluating the new complaint, filling out workers- compensation paperwork (see 99455-99456), and such.

This must be face-to-face time between the patient and the physician. If a staff member completes the paperwork, you cannot count the time. Keep in mind that the prolonged services must be 30 minutes beyond the time established for the level of service documented and billed. The documentation for prolonged services should clearly include:

- total time the physician spends face-to-face with the patient;

- amount of time beyond the usual time for the service level documented and billed (must be at least 30 minutes or more); and

- the reason why the physician prolonged the service.

Note: If the optometrist is performing a consultation -- 99241-99245 (Office consultation for a new or established patient -) -- then you would bill the consultation codes regardless of whether the patient is new or established. The consultation codes do not differentiate between new and established.

Best bet: Check your state's WC regulations before billing any WC claim. Each workers- compensation jurisdiction may set their own rules and regulations.

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