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Consultation versus New/Established?

  1. Default Consultation versus New/Established?
    Medical Coding Books
    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
    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
    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. Default
    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. Default
    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
    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. Default
    Thank you for that link Holly. I think this is going to help me out a lot.


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