Coding & Reimbursement

New Definition, New Patient

By Suzanne L. Corcoran, COE

The American Medical Association, creator of the CPT Handbook, occasionally changes definitions in the book. In 2012, the definition of a new patient was changed, and this is creating more questions for practices. I'll deal with some of the more critical ones here.

Q What is the CPT definition of a new patient, and how has it changed?

A CPT 2012 says: “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

The phrase “exact same specialty and subspecialty” is new. This would mean that a patient seen for the first time by a cornea specialist and a retina specialist in the same group within a short interval of time (or possibly the same day) would be a new patient for each ophthalmologist. Because a new patient office visit has higher reimbursement than an established patient office visit of the same level, this seems like good news — except that third-party payers, including Medicare, are not on board. Within CMS, all ophthalmologists belong to specialty 18.

CMS makes no distinction between cornea and retina specialists, for example, so two claims submitted in accordance with CPT's instructions would not be processed as hoped. Instead, only one of them would be a new patient, and the other claim would be reclassified as an established patient. As a practical matter, there has been no change in the definition of new patients from the payer's viewpoint.

Until payers make a distinction, upon enrollment, between subspecialists within ophthalmology, there is no reason to file claims differently.

Q What about optometry and ophthalmology?

A It is important to note that optometry and ophthalmology are different specialties, so this change in CPT may serve as a reminder of that fact. Optometry is specialty 41 within CMS. Nevertheless, many group practices do not call attention to this difference because it is convenient to schedule patients with either an optometrist or ophthalmologist based on availability or presenting complaint.

Also, because reimbursement rates for optometrists and ophthalmologists are identical, the distinction is not financially meaningful.

Q What is the effect of two visits within a short timeframe?

A When two different physicians in the same group see a patient within a short period of time, the second office visit is commonly abbreviated compared to the first because there is rarely medical necessity to repeat every element of the history and exam. Also, because the CPT requirements for new patient evaluation and management (E/M) codes are more demanding than the same level of service for an established patient, there may be an unexpected and unpleasant result.

The level of service for the second eye exam in the new patient category could easily be lower than would otherwise be the case in the established patient category, resulting in less reimbursement. For example, consider an exam with a problem-focused (PF) history, an expanded problem-focused (EPF) exam, and low medical decision making.

This meets the criteria for an EPF established patient visit (99213), which has 2.07 RVUs (approximately $78 nationally). The same exam billed as a new patient would only meet the E/M criteria for 99201, which has 1.25 RVUs (approximately $48 nationally). No such counterintuitive result occurs with eye codes, but it is questionable whether such an exam would qualify for an eye exam code.

Q What other issues should we consider?

A We wonder what effect this change would have on the goodwill of the practice if patients are unexpectedly reclassified as new patients. Would patients object? Would it take more staff time to explain and justify the switch? Would patients be persuaded by the explanation?

Finally, we approached an official at the American Academy of Ophthalmology for another perspective. We were advised that AAO is not suggesting or recommending a change until the payer community is on board with CPT; that might take a while. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.