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General Surgery Coding Alert

You Be The Coder:

Can 'New' and 'Established' Affect Consults?

Published on Wed Feb 25, 2004

Question: May I bill a consult for an established patient (last seen two years ago) seen by a new surgeon in our office? This is a new episode of the same problem the patient had earlier.

New Mexico Subscriber


Answer: Although standard outpatient visits distinguish between new (99201-99205) and established (99211-99215) patients, office consults (99241-99245) require no such distinction. Rather, consults apply to new or established patients.

When determining if you may report a consult, you must demonstrate that you have met the minimum requirements of a request (from the physician sending the patient for the consult), a opinion rendered (by the consulting physician), and a written response (from the consulting physician to the requesting physician), which outlines findings, diagnosis(es), treatment recommendations and other relevant information. If the visit does not meet any of these three requirements, you cannot bill for a consult.

If the visit does not meet the requirements of a consult, you should choose an appropriate-level established patient E/M visit (99211-99215). CMS regulations define a "new" patient as one who has not been seen by the physician or physician practice within a three-year period. In this case, another physician in the same practice saw the patient two years ago, so  the patient is "established."

Remember: All physicians within the same practice (that is, all physicians sharing the same tax identification number) are "interchangeable" from a billing standpoint.

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