Optometry Coding & Billing Alert

Question: When I cover for another local private-practice optometrist, I code the office visits as established patient E/M services. If, a couple of weeks later, a patient decides to switch to my  practice permanently, should I report a new or an established patient office visit? This visit will require all necessary new patient paperwork.

Tennessee Subscriber

Answer: You should report a new patient office visit code (99201- 99205) for your E/M service. You could certainly use the ophthalmic exam codes (92002 or 92004) and not have to document so carefully.

As a covering physician, you temporarily replace the patient's regular physician, and bill the type of care the regular physician  would have reported. As in your example, the patient was established, so it is correct to report an established service to the insurer. If the patient then comes to your practice to specifically see you, the patient would be new to the practice and you could use a new patient office visit code (99201-99205, Office visit for the evaluation and management of a new patient ...).

But when the same patient comes to your office to establish a relationship, you have no paperwork regarding the patient, and your records don't indicate that you provided any professional services to the patient in the past three years. Because the visit meets CPT's definition of a new patient, you should assign the appropriate-level new patient office visit code.