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Thread: Consultation versus New/Established?

  1. #1

    Default Consultation versus New/Established?

    AAPC: Back to School
    Okay I have a question regarding consultations.

    What is the deciding factor in assuming responsibility for the patient's condition?

    I have a general surgeon that is consulting for a primary care. The patient has abdominal pain and the primary care wants the surgeon to consult. If my surgeon orders diagnostic testing but doesn't 'treat' the patient, that's still a consult right? If, in the course of the exam, the surgeon decides that he needs to do an appendectomy, that wouldn't be a consult?

    Our surgeon is wanting to bill a consult for every patient that is coming in from another physician and I'm just having trouble. I'm just not sure where the line is.

    thank you,

  2. #2
    Join Date
    Apr 2007
    St. Louis, Missouri


    Yes, you can perform diagnostic testing and it is still a consult. As far as deciding that the patient needs an appendectomy, I would still say this is also a consult. If the PCP has asked for a consult due to abdominal pain and you decide that the patient needs surgery during your exam of the patient, as long as you are sending a letter back to the PCP as to your findings and what you think is the correct course of treatment, I would think this is still a consult. I am curious to see what some other coders think of this situation.

    Melissa Blow, CPC

  3. #3
    Join Date
    Apr 2007
    north seattle wa

    Default consult vs referral

    To eliminate some of the problems with this, our practices have a form that we have sent to other physicians that are sendingus patients. I has 2 different boxes on it, 1 that says Requesting consultation of _______ problem and the other says Referral for _________. This way there is no confusion when it comes to the billing.
    Hope this helps.


  4. #4


    This is still confusing for me.

    Under Consultations in the CPT Manual, it says " If subsequent to the completion of a consultation the consultant assumes responsibility for management of a portion or all of the patient's condition, the appropriate E and M codes should be reported."

    If the surgeon has diagnsosis appendicitis and has decided to do the surgery, aren't they assuming responsibility during the consultation?

  5. #5


    It is my understanding that you would bill for a consult, if the MD decides to have the patient return for a follow up visit, then you would not use consult code. Consults should only be billed if you have a written request so if the referring doctor didn't send another request for opinion, then it is not a consult. Hopefully this makes sense.

  6. #6
    Join Date
    Apr 2007


    It is confusing but just because the physician then follows the care of the patient doesn't mean the initial visit wasn't a consult. In the August issue of the Coding Edge, page 25, it explains consult vs. transfer of care in the case of a hospitalists but it may help explain this better for you.


    Best of luck. Holly M.

  7. #7


    Thank you for that link Holly. I think this is going to help me out a lot.


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