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Issue Number - Name
0039 - Not a New Patient – Ophthalmology Codes
Review Type
Automated
Claim Type
Physician, Professional Services
Region and State
RAC 1-4
All States
Date Approved
2017-03-09

Description

Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any face-to-face service from the physician or physician group practice (limited to physicians of the same specialty) within the previous 3 years. This query identifies claims for patients who have been seen by the same provider in the last 3 years but for which the provider is billing a new (instead of established) visit code.  Findings are limited to line with overpayments only.

Affected Codes

  •  92002, 92004

Applicable Policy References

  • Social Security Act, Section 1833 [42 U.S.C. 1395l] (e)
  • CMS Pub. 100-04, Claims Processing Manual, Chapter 12, 30.6.7 (A)