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Consulting Confusion

  1. Question Consulting Confusion
    Medical Coding Books
    I work in a ENT specialty practice with 4 docs, and am having an issue with the coding of consults with one of them.
    The doc will bill a consult for pt Joe Doe, with a dx of chronic sinusitis. He will then perform any procedures needed (scope, etc..) along with the office visit. In his opinion, if he discharges the pt from his care, along with documentation in the pt's med recs stating that he is done treating the issue, he can then turn around and bill another consult at any point for this same pt with the SAME DX if the requesting physician sends the pt back. Is this appropriate?

    I understand that a consult can be for a new or established pt, but how many consults can one doc charge for a pt, if they are continually sent back to our doc, even with the same dx?
    I'm looking for documentation from an official source to show my doc. Does anyone have any suggestions?

    Thanks for your help,


  2. #2
    North Carolina
    If an additional request for an opinion or advice, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) may be used again. However, if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.

    Rebecca CPC, CPMA, CEMC

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  3. #3
    Milwaukee WI
    Default Why is the patient returning?
    You say the patient is being "discharged" from care ... so I'm going to assume that this isn't a follow-up visit that has been scheduled at the request of your ENT doc.

    Is the patient returning because the "requesting" physician doesn't do scopes and knows the patient needs one? Then that's a transfer of care, NOT a consult.

    Is the patient returning because the 'requesting' physician has done all s/he can as per the advice from the original consult and is now asking "what else can we do?" Then it's another consult.

    F Tessa Bartels, CPC, CPC-E/M

  4. #4
    If a doc sees a patient for a consult and then schedules pt to come back for a procedure..would that be a transfer of care where a New patient E/M could be billed as well as the procedure?

  5. #5
    Milwaukee WI
    Default Consulting doc requests follow-up
    If you see a patient in consultation and request that the patient return for follow-up visit the next visit(s) is an established patient office visit.

    If you are asking the patient to return for a procedure, then there is NO E/M service at the visit where the procedure is performed; you'd code only the procedure. All procedures have RVUs that include the basic evaluation of the patient attendant with the procedure. The only exception is when the E/M is necessary for the decision for surgery. BUT in your example the "decision for surgery" is made at the initial consultation.

    Hope that helps clear things up.

    F Tessa Bartels, CPC, CPC-E/M

  6. Default oto - ent
    I have surgeons in my practice and so I am wondering if a PCP refers to Dr. A and he can't resolve but says oh go see Dr. B (same practice) how is this billed who would get the benefit of the consult or do they both.

  7. #7
    Refer indicates a transfer of care, ie new patient not a consult.

    If Dr. A can't help the patient and sends them on to Dr. B in the same specialty then Dr. B bills an established patient visit. If Dr. B is in a different specialty, they would bill a new patient visit.

    Of course you have to keep in mind the definition of a new patient as well.

    If the initial visit was truly a consult, Dr. A would bill a consult code and then just send the patient back to the PCP with their recommendations. If Dr. A does the consult then sends the patient directly to Dr. B, that visit would be an established patient visit.

    This can be so complicated sometimes....

    Laura, CPC

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