New Patient vs. Consultation


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Am I understanding correctly that a new patient equals a transfer of care and a consultation is an opinion/advice regarding management of a specific problem?

We are an oncology/hematology practice that will often receive referrals from physicians wanting us to evaluate a blood disorder or clear someone who has abnormal labs for surgery. This is from what I understand a consultation and codes 99201-99205 apply.

But if a patient is referred to us because they have a newly diagnosed cancer and we will be treating the patient and caring for that diagnosis....then it is NOT a consult and new patient codes 99201-99205 apply.

Am I correct??

I am new to this and any information you have would be greatly appreciated.:confused:
Central Pittsburgh
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It's not so much why they came to see you, it's the intent of the visit.

If the requesting physician asks your opinion as he/she doesn't know what course of treatment or a definitive diagnosis, then this could be a consultation. However, if it is clear what the diagnosis is and the MD wants you to handle it and doesn't want to be made aware of the goings on, then it would be a new patient.

You as the consultant can still order testing, perform services, etc. and it still be considered a consultation.

It's all about the intent.

Suzan Hvizdash, CPC, CPC-E/M, CPC-ED


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Does anyone know where I can find this information in writing possibly on the CMS website or aapc website so that I may reference it to my office administrator?
Albany, NY
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Link to CMS Manual

30.6.10 - Consultation Services (Codes 99241 - 99255)
(Rev. 788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)
A. Consultation Services versus Other Evaluation and Management (E/M) Visits
Carriers pay for a reasonable and medically necessary consultation service when all of
the following criteria for the use of a consultation code are met:
• Specifically, a consultation service is distinguished from other evaluation and
management (E/M) visits because it is provided by a physician or qualified
nonphysician practitioner (NPP) whose opinion or advice regarding evaluation
and/or management of a specific problem is requested by another physician or
other appropriate source. The qualified NPP may perform consultation services
within the scope of practice and licensure requirements for NPPs in the State in
which he/she practices. Applicable collaboration and general supervision rules
apply as well as billing rules;
• A request for a consultation from an appropriate source and the need for
consultation (i.e., the reason for a consultation service) shall be documented by
the consultant in the patient's medical record and included in the requesting
physician or qualified NPP's plan of care in the patient's medical record; and
• After the consultation is provided, the consultant shall prepare a written report of
his/her findings and recommendations, which shall be provided to the referring
The intent of a consultation service is that a physician or qualified NPP or other
appropriate source is asking another physician or qualified NPP for advice, opinion, a
recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient
because that individual has expertise in a specific medical area beyond the requesting
professional's knowledge. Consultations may be billed based on time if the
counseling/coordination of care constitutes more than 50 percent of the face-to-face
encounter between the physician or qualified NPP and the patient. The preceding
requirements (request, evaluation (or counseling/coordination) and written report) shall
also be met when the consultation is based on time for counseling/coordination.
A consultation shall not be performed as a split/shared E/M visit.
B. Consultation Followed by Treatment
A physician or qualified NPP consultant may initiate diagnostic services and treatment at
the initial consultation service or subsequent visit. Ongoing management, following the
initial consultation service by the consultant physician, shall not be reported with
consultation service codes. These services shall be reported as subsequent visits for the
appropriate place of service and level of service. Payment for a consultation service shall
be made regardless of treatment initiation unless a transfer of care occurs.
Transfer of Care
A transfer of care occurs when a physician or qualified NPP requests that another
physician or qualified NPP take over the responsibility for managing the patients'
complete care for the condition and does not expect to continue treating or caring for the
patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for
an opinion or advice to personally treat this patient and is not expecting to continue
treating the patient for the condition. The receiving physician or qualified NPP shall
document this transfer of the patient's care, to his/her service, in the patient's medical
record or plan of care.
In a transfer of care the receiving physician or qualified NPP would report the appropriate
new or established patient visit code according to the place of service and level of service
performed and shall not report a consultation service.


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remember the "3 R's"


in order to bill a consult code you must have a REFERRAL from another physician
This must be documented in the chart and is easiest done by asking for a script to be faxed to you from the referring physicians office along with any pertinent records. The script should say something like "evaluate" or "evaluate and treat" and should include the diagnosis/signs/symptoms/abnormal findings

Your physician must RENDER the consultation service.

Your physician must REPLY in writing stating his/her opinion and recomended course of treatment. If your physician ordered any testing he/she should also indicate such in his/her letter.