Wiki New patient visit / Consultation appointment

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sfruslik

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Hello all,
I hope someone could shine a light on the following question for me..Which code should be billed for a consultation (a new patient that has never been seen before)
Here is a scenario...I work for a specialists office, treating sleep apnea. A patient is referred for a consultation by their care-team member, either a pcp or sleep specialist.
I've noticed that our biller is billing 99203, but I'm trying to figure out why not 99243 instead?
Again, this is a first, never have been seen before visit, for a patient consultation to explore if treatment option that my specialist provides is applicable to treat a referred patient for a diagnosed condition.
Thank you all for the time and help in advance.
 
A consultation is requesting an opinion. The provider needs to submit a report back to the requesting provider. There is already a diagnosis.
 
Thank you both for your responses, and help, I greatly do appreciate it.
I guess what is unclear to me, pardon for being blind, but if a requesting provider refers a patient with a diagnosis to another specialist for a consultation on appropriate treatment options of said diagnosis, why wouldn't that be a 99243? Obviously my provider types up a report with findings, proposes appropriate treatment option, if that patient qualifies, and sends a report to both, a referring provider and insurance company with a request for an authorization of treatment.
Again, my apologies for sounding dumb on this issue, I just want to get a clear understanding of the difference between two codes in this particular scenario. Thank you again for the time and help with this in advance.
 
sfruslik said:
Thank you both for your responses, and help, I greatly do appreciate it.
I guess what is unclear to me, pardon for being blind, but if a requesting provider refers a patient with a diagnosis to another specialist for a consultation on appropriate treatment options of said diagnosis, why wouldn't that be a 99243? Obviously my provider types up a report with findings, proposes appropriate treatment option, if that patient qualifies, and sends a report to both, a referring provider and insurance company with a request for an authorization of treatment.
Again, my apologies for sounding dumb on this issue, I just want to get a clear understanding of the difference between two codes in this particular scenario. Thank you again for the time and help with this in advance.
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In your case, there may be no difference at all, except on whether or not the insurance will pay a consult code.

A consultation is an E&M 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.

There is a phrase - "the three Rs of consultation". This is request, render, report. There must be a documented request for your doctor's opinion. He must render an opinion. He must report back to the requesting physician in writing.

A lot of doctors officers say "refer and treat" or "consult and treat" when they send over a consultation. To me, that's not enough. They need to say, "Patient has symptoms of x, y and z. I suspect he has sleep apnea. Please evaluate patient and let me know your recommendations, and treat if warranted."

That is asking for an opinion. You've already got the report back, so that part is handled. To me, the consult request matters.

Here is an example. We are pain management. If a primary care doctor sends a consultation request over, it should say something like this: "Patient has had (history of pain). I have been treating patient with (medications, treatments, whatever). His pain levels remain at 5 to 6/10 on a regular basis. Please evaluate and render your opinion on whether this patient's pain can be better managed." This gives my boss the opportunity to evaluate, report back, and even say something like, "We have had good success with buprenorphine in bringing pain levels down to 2 to 3/10, if the patient is willing to titrate down on opioids and even stop them altogether. The patient is amenable to this plan. If you would like me to take over this patient's pain management, I would be happy to do so."

Of course, if the insurance is no longer accepting consult codes (such as Medicare), it doesn't really matter. You would bill the new patient visit anyway.
 
@SharonCollachi
Thank you very much for your response, I truly do appreciate it.
You are absolutely correct, we do get our referrals sent with "consultation+treatment" or "evaluate and treat" on a referral slip. With that said, I think it will be easier to go with 99203 then asking a referring doctor to submit a referral with an appropriate language :)
Thanks again for all the time and help!
 
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