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Eli's Rehab Report

Reader Question:

Referred Patients

Published on Fri Feb 01, 2002 Print Friendly and PDF PDF

Question: I work for a physiatrist who does not use any new patient CPT Codes . Because all of his patients are referred to him, he says that none are actually "new." He writes a report back to the primary care physician, so he uses only the consult codes. However, he usually takes over the care of the patient's illness and makes several follow-up appointments. Is this correct coding?

Illinois Subscriber

Answer: The word "refer" can be tricky: Not every referral qualifies as a consultation, even if the physiatrist sends a report back to the referring physician.
 
If the patient is actually referred to the physiatrist (the referring doctor wants the PM&R specialist to evaluate and take over care), then the physiatrist should treat the patient as a new patient and bill using a new patient code (99201-99205).
 
Note: CPT defines a "new patient" as one "who has not received any professional services from the physician or another physician of the same specialty" in the same group within the past three years.
 
If the second physician saw the patient for a consultation (99241-99245) and took over the patient's care after the first visit, the first visit would be treated as a consult and subsequent visits as established patient E/M visits (99211-99215).
 
A lot depends on the intent of the first visit. If a formal request for opinion, review of the patient and report back to the referring physician took place, you probably have a true consultation. However, if an orthopedist sends all of his arthritis patients to your practice for you to take over care, you cannot bill consultations for all of them because they qualify as transfer of care. 
 
The report back to the referring physician is often done as a courtesy when one physician refers a patient to another; however, that fact alone does not serve as proof that a consultation took place. If the patient's record includes a fax from the referring physician saying, "I am sending Judy Smith to you to assume care for multiple sclerosis," you cannot consider that fax a request for opinion. This is a transfer of care, which would constitute billing a new patient E/M code and not a consult. If, however, the letter said, "Please review Judy Smith's condition to evaluate whether she has multiple sclerosis and send a report back to me with your findings," then you have a request for opinion, which would more likely substantiate billing a consultation code.
 
The Office of  Inspector General (OIG) is scrutinizing consultation codes as part of its work plan for 2002, knowing that some physicians take advantage of the higher RVUs set for consultations versus established patient E/M visits. Even if this were not the case, your practice would most likely fall out of the "normal" range for the high number of consultations billed versus office visits, and you could be contacted by the OIG for an audit. Review your files to ensure that your consultations meet all of the billing criteria.

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