New Patient Exams


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Recently I attended the WAEPS billing code quest seminar and something the speaker said raised a lot of questions. I have always billed a new patient as a patient that has not been seen by our practice in the last three years or at all, but the speaker said that if a patient is seen by a optometrist as a new patient and referred to an ophthalmologist in the same practice, but different taxonomy code then both could bill for new patient exams because of the different taxonomy codes regardless of the tax ID, to me this just seems wrong, but when questioned the speaker stood by what she's said. Has anyone encountered this?


True Blue
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The speaker was correct - if the patient is new to the specialty, the visit should be billed is new even if they have been seen within the practice by a physician of a different specialty - they only become established when seen within three years within the same specialty - this is per CPT guidelines. But I'd add that different payers identify specialties in different ways and it isn't always by taxonomy. Medicare does not use taxonomy, but instead uses the specialty that the provider identifies on their CMS-855i enrollment form, but I'd also point out that Medicare lists both Optometry and Ophthalmology on the form as separate options.