Wiki hospital vs office billing

[NikkiK]

Our PAs/MDs see pt's at the hospital but the hospital bills for their services under their tax ID #. If the pt then comes to our office upon discharge & is a new pt to our practice can we bill for a consult even if they were seen by one of our practitioners but we did not bill for it?

 

[mjohnso1]

New patient visit

Per CMS Medicare, the visit in the office after a hospital visit would not be considered new if provided by the same provider or group. However, you may want to check if the hospital is billing a professional service for your providers.

Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.

 

[lorrpb]

The encounter does not meet the definition of a consult, which is one provider asking another provider for an opinion. Must include documentation of the request and the report back to the referring provider. Whether or not the "consulting" physician previously saw or billed for the patient is not relevant.

CPT Guidelines:
"A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.
The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source. "