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i'm confused about NP & Est. pt codes

  1. Default i'm confused about NP & Est. pt codes
    Medical Coding Books
    I have a question about the 92002 to the 92014 for new or established patients. My question being that medicare specifically in their guidelines for billing states that these CPT codes are billed following the services of cataract surgery. What if a Medicare patient just comes in for a eye exam that was recommended by their PCP? If there new patients' woud I use a code from HCPCS? I have just started this billing job at this Optometry practice and I see the same denials from medicare over and over for the 92014. I'm trying to get them on the right track. I also see denials for the 99213 code. I'm thinking that they are not using the proper dx codes that medicare recognizes for coverage of these services? could someone please let me know. Thank you!!!

  2. #2
    Charm City - Baltimore
    A New Patient is one that has not been seen by your provider in the past 3 years.

    An Established Patient is one that has been seen within 3 years.

    If a patient is coming in because their PCP said they needed an eye exam, then your practice needs to ask "have they been seen within 3 years" to know if they are new or established.

    Once you've established "New" vs. "Established" status, go over the definitions for what qualifies an "Intermediate" and "Comprehensive" visit beginning on page 461 of CPT 2011. Read that to know the differences and then review the documentation. What was done on this patient?

    Hope this helps!
    Crystal, CPC, CCS-P

  3. Default
    sorry to get back to you so late Crystal..Thank you so very much for your answer. I'm quite familiar with new and est patients, however, I guess, I really didn't clearly post the question to which I needed an answer. I thought Optometry would be a simple specialty to tackle, but it can be quite confusing at times in that all the insurance carriers are definitely different in what they will cover and what they will not and what is confusing is E/M vs. Medicine codes for new and established and that is what I was trying to get some advise on.....sorry, I'm even making myself a little confused....LOL! Any advise you can give me, I would truly appreciate it! I'm sure that the dx code plays a big part in this as well? Thank you any advise, I would gladly appreciate it!

  4. #4
    What are the reasons given on those denials? The dx does matter - Medicare and many insurances will never pay for any service for routine vision - that is with a dx of myopia, hyperopia, astigmatism, etc. Medicare also will never pay for a refraction or a contact lens fitting, even if the contact lens fitting is for a medical reason such as kerataconus. You mentioned patients that have had cataract surgery. Are these recent surgeries (in the 90 day post op period) or just a history of cataract surgery?

  5. #5
    You can bill the medically necessary contact lens fitting to medicare, but it has to be billed to your dmerc (supplier) (who you'd bill for post cataract surgery glasses).
    Jennifer DeWitte, CPC, CPC-P, CPB, AAPC Fellow
    Newport Center Surgical
    Coding & Billing Department
    Vice President
    AAPC Fullerton, CA Chapter

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