billing & coding
Coding Follow-Up Office Visits
How do you bill a new patient for multiple, subsequent visits?

I recently received an inquiry from an optometrist in Virginia. I thought I'd share her concerns and my response with you. This optometrist provides the scenario of a new patient who presents with pain, photophobia, conjunctival redness and blurred vision and is diagnosed with a corneal ulcer. Presumably, the patient is advised to, and returns for follow-up care the next day, the third day and the fifth day after the initial visit.

The O.D. asked whether it was appropriate to bill for visits that occur close together, for example on a Monday and on Tuesday, on the next day. Additionally, should she collect applicable co-payments on back-to-back days? Thirdly, the doctor questions whether a certain billing rationale is justifiable for the corneal ulcer scenario. She proposes billing a new, level four (99204) on day one, followed by an established level three (99213) on the second and an established level two (99212) on the third visit.

To bill or not to bill

As to whether it is appropriate to bill for each visit separately, the answer is absolutely. Each visit on each day in this scenario is a separate billable visit composed of the three key components of any medical evaluation and management visit: history, examination and decision making. Evaluation and management (E/M) visits are performed from start to finish on one day, including the billing for the visit. Comprehensive eye examinations do not have to be completed in one visit but may be billed on first visit and completed on one or more successive visits. This often occurs when patients return the next day to complete the exam.

Co-payments

Secondly, this practitioner asks whether collection of co-payments or co-insurance is proper billing procedure for each visit. For E/M visits, bill each visit separately and if collections of co-payments or co-insurance are part of the insurance contract, you should collect them at each visit. This holds true even if the visits are on back-to-back days.

Appropriate visit levels

The third part of this inquiry is more complex. This practitioner outlines a coding plan for the three consecutive visits and questions the rationale behind the chosen levels.

The only sure way to accurately determine if these E/M levels are correct is to review the medical record documentation and ensure that the level of history and exam (problem focused, expanded problem focused, detailed, or comprehensive) and the complexity of decision making (straight forward, low complexity, moderate complexity or high complexity) are documented and justified by the chief complaint for each visit. You should only do this at the conclusion of the patient visit and once you have completed the medical record documentation.

Some practitioners reduce the level of service at a subsequent visit without reviewing the medical record. This is a bad habit. In fact, in some cases the initial visit might be coded as 99203 and a second visit could be 99214. It's important to remember that under-coding is just as inaccurate as over-coding.

New or established?

If you or a partner has not seen the patient in the last three years, then the visit is considered new. On the next day, the patient is aptly coded as established.

Again, it's essential to have a coding guide available to simplify E/M coding, as well as up to date CPT and ICD-9 resource books. And it never hurts to ask for advice. We're all in this together.

DR. MACK IS DIRECTOR OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.