New patient visit

When an existing patient sees a new physician in the group, it is not a new patient visit.

A patient was first seen by a senior ophthalmologist within your group practice. Two years later, the patient returns for re-evaluation, but the senior ophthalmologist has retired in the meantime. Another ophthalmologist sees the patient instead. The patient has never been seen by this physician before. On this occasion, the new doctor takes special care to become acquainted with the patient’s prior records and to extensively update the medical history.

Is this visit billable as a new patient visit?

No, the patient qualifies as an established patient. According to the Evaluation and Management Services Guidelines in CPT, “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 3 years.”

It is interesting to note the emphasis on same specialty. In large medical groups with an array of physicians, there is no hindrance to using new patient visit codes when the patient is seen in different departments (eg, internal medicine and ophthalmology). However, while optometry and ophthalmology are likewise considered to be different specialties, we have not found it practical to apply this distinction in a group consisting exclusive of optometrists and ophthalmologists. Instead, a lot of effort is expended to create a fluid path between optometry and ophthalmology in mixed groups and not establish barriers.