Ophthalmology and Optometry Coding Alert

Question: An ophthalmologist saw a patient in the emergency department (ED) whom our group had never previously treated. During the encounter, which we billed as a consultation, the ophthalmologist told the patient to follow up with an office visit in two weeks. Should I code a new patient office visit?


Arkansas Subscriber


Answer: No. You should report the outpatient service as an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) or an eye examination (92002-92014, Ophthalmological services: medical examination and evaluation ...).

Why? The patient meets CPT's definition of an established patient. "An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years,"  CPT's E/M guidelines state.

In your scenario, the ophthalmologist provided professional services to the patient within the past three years - within the past two weeks, to be exact. Therefore, you should bill 99212-99215, not 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...).

The place of service doesn't affect the patient's status. CPT differentiates a new patient from an established patient based on whether the patient received professional services from the physician. The definition doesn't distinguish between locations. So the fact that the first service occurred in the ED and the second E/M took place in the office doesn't affect the patient's status.

Remember: You don't have to determine a patient's status when reporting an ED visit (99281-99285, Emergency department visit for the evaluation and management of a patient ...). Codes 99281-99285 don't distinguish between new and established patients.