Optometry Coding & Billing Alert

Question: An optometrist is new to our practice from another practice in town. Some of her patients have followed her from her previous practice to our practice. Should I bill the patients as "new patients" on the basis that they are new to this practice and group number, or should I bill a visit as an "established patient" because the provider saw the patient at her old practice?

Delaware Subscriber

Answer: You should bill as established patients (99211-99215) any patients whom the optometrist saw at her previous practice within the past three years and now sees at your practice for the first time. The CPT new/established patient definition applies to the provider-patient relationship, regardless of location.

"A new patient is one who has not 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," according to the E/M services guidelines.

Although the patients you describe are coming to your office for the first time, the transferring optometrist has already provided services to them, and thus you should consider the patients "established." The italicized portion of the above new patient definition also means that if another optometrist within your group sees the patient at your office before the joining optometrist does, the patient is still established. Because one provider of the same specialty in your group has seen the patient within three years, the patient is established, regardless of whether that optometrist has previously treated the patient.

CPT's definition is based solely on whether a patient has received professional services from any of the practice's providers within the past three years. Using a different identification number doesn't change the relationship. Although the optometrist was not part of your practice when she first established care with the patient, your practice does not get to reclaim the patient as new, meaning new to an identification number.

Even if you have to create the above patient's paperwork and charts for the first time at your practice, you should not consider the patient "new."