Medicare Compliance & Reimbursement

Question: If my doctor sees a patient in the office for something like diabetes, then the patient is admitted for something else and the admitting physician consults my doctor about the diabetes, is it a new consult?

Answer: In this case the coding would depend on the payer’s consultation rules.

If following Medicare rules, in-hospital consultations are billed with the initial hospital visit code 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) whether the patient is old or new.

The same holds true if the payer follows CPT^® rules. In-hospital consultations would be billed with the older CPT^® codes 99251-99255 (Inpatient consultation for a new or established patient …) whether the patient is a new or old patient.

All this assumes that consultation requirements are met. If there is no consultation requested, and the admitting physician only wishes your provider to also follow the patient for the known diabetes, and no formal request has been made by the admitting physician for your provider’s opinion, you should report a follow-up hospital care code from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

In the office for Medicare if a consultation is requested, the provider should bill an established patient code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …), as this patient in your scenario is not a new patient but was treated by the provider during the last three years. However, following CPT^® rules a consultation in the office is coded with 99241-99245 (Office consultation for a new or established patient …).