Something Old, Something New, Something...

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I recently had a question about billing a new vs established patient that is not a commonly encountered issue but can make a difference to our practices.

The question was this: "If I have an associate doctor [I will call Dr. A] who used to work at another practice across town and [Dr. A] saw a patient at his previous practice (not affiliated with ours) last year and when [Dr. A] came to our practice and saw the same patient here this year, do we bill that as new or established?"

According to CMS a new patient is: "a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years."

So the answer is, since they saw the same physician (even if it was at a different location) in the last 3 years, the patient would be coded as an established patient. Had they seen another physician (one they had never seen) in the NEW practice, the patient would have been coded as a NEW.

In researching the answer, I wanted to make sure I understood the CMS wording of "or other face-to-face- service". It turns out that if the patient was sent to Dr. A to have a 30-2 visual field and Dr. A ran and interpreted the filed, and never actually saw the patient for an office visit (99-code or 92-code) then the patient would be NEW if he saw Dr. A at the new practice 1 year later.

So why does this all matter? Well, most of the time it makes no difference to a vision plan (VP) if a patient is new or established. The VP will reimburse the same amount for a new patient or an established patient. But the new/established rules make a significant difference when billing visits to medical insurances and following the 95 and 97 documentation guidelines.

One quick example is the examination element difference between 99203 (new) and 99213 (established).

Remember that for new patients, the code level is based on all 3 of the areas of the encounter.

99203 (minimum):

  1. History - Detailed

  2. History of Present Illness (HPI) - 4 elements

  3. Review of Systems (ROS) - 2 elements

  4. Past, Family and Social History (PFSH) - 1 element

  5. Examination - Detailed - 9 elements

  6. Medical Decision Making - Low

  7. Diagnosis and Management Options - 2 and/or

  8. Complexity of Data - 2

  9. Risk - Low

For established patients we only score 2 out of 3 areas (one being MDM).

99213 (minimum):

  1. History - Expanded Problem Focused

  2. HPI - 1 element

  3. ROS - 1 element

  4. PFSH - none

  5. Examination - Expanded Problem Focused - 6 elements

  6. Medical Decision Making - Low

  7. Diagnosis and Management Options - 2 and/or

  8. Complexity of Data - 2

  9. Risk - Low

Outside of MDM, you can see that there is a significant difference in the number of examination elements and history required for a 99203 and a 99213. The monetary difference between billing a 99203 and 99213 can be significant to a practice.

If you need a simple and yet comprehensive overview of optometric billing and coding, you can find our complete course here.