Wiki Established patients being seen in hospital

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KaylaRieken

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I work at a urology office. We get called to come do consults on inpatients/outpatients/patients in the ER often. When this happens, we are seeing established patients that obviously have established problems with us. Are there any rules I should know about this?
 
Hospital codes do not differentiate between new and established.

Remember that a consultation is a specific request for your provider's opinion on a problem. Not "hey, I have your patient here, can you come see him?"
 
That's not what I meant. I meant as far as determining who is a new patient and who is established.

An existing problem is not a new problem.
 
Ok. I think that is where I am confusing myself. So an existing problem is still considered an existing problem and can only be counted as 1 pt or 2 pts?
 
Ok. Someone once said that all problems in the ER are new?? But that isn't always true then. It could be an established problem just worsening.
 
When your dr is requested to do a consult on an ER patient:
* If the insurance accepts consult codes, then 99241-99245. If insurance does not accept consult codes then use new patient 99202-99205 (not seen by your specialty in last 3 years) or established 99212-99215.
* If patient has Medicare and your doctor sees them in consult in ER, then use ER codes 99281-99285.
* If the patient was already admitted to inpatient, use inpatient consult codes 99251-99255. However, if the insurance does not accept consult codes, then use 99221-99223 for new or established patients as the initial visit. If your doctor sees the patient again in that same hospital admission, then followup inpatient codes should be used 99231-99233.
Hope that helps!
I work for a hospital in NJ....not sure if rules are different in each state.
 
kfalcone said:
When your dr is requested to do a consult on an ER patient:
* If the insurance accepts consult codes, then 99241-99245. If insurance does not accept consult codes then use new patient 99202-99205 (not seen by your specialty in last 3 years) or established 99212-99215.
Click to expand...

I disagree. You do not use 99202-99205 for services in an ER, whether the patient is new or not, as the concept of new patient does not apply to the ER. You would use the ER codes.
 
KaylaRieken said:
Ok. Someone once said that all problems in the ER are new?? But that isn't always true then. It could be an established problem just worsening.
Click to expand...

Some E&M audit tools identify new/established problems as either new 'to the patient' or new 'to the provider/examiner'. The Medicare contractor, NGS, in the region where I work uses the 'to the patient' definition. So in this case, if the patient has been previously diagnosed for this problem, it would be considered an established condition, regardless of whether the particular provider is seeing the patient for the first time.

However, to add to our confusion, they have also given guidance that states: "The concept of a “new” or “established” problem does not apply to patients seen in the ER. All patient problems are considered “new” in the ER setting, except those for which the patient presents on multiple visits on the same date of service."

So in most cases we would still consider the problem new if the patient is being evaluated in the ER. But check with your own payers to see if they have any guidance on this.
 
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