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Need Consult Clarification..please

  1. Default Need Consult Clarification..please
    Medical Coding Books
    Hi everyone,

    I have been asked a question from a doc regarding a consult. And I am not sure of the answer. Perhaps you all can help!

    If the physician sees a patient for a consult on a specific condition. The physician sends the plan/advice and the patients condition resolves... but then reappears 4 months later. Technically, it is a new condition but can the physician bill another consult utilizing the same dx code?

    My thought is, technically it is correct and the docuemtnation willhave to clearly state another new condition and then it will be denied by insurance and will have to be fought on appeal.

    ANy thoughts?


  2. #2
    East Stroudsburg, PA
    According to the Medicare Guidelines, an additional request for an opinion or advice regarding the same or a new problem with the same patient is received from the same physcian and documented in the medical record the consultation codes can be used again. However, if the consult continues to care for the patient for the original problem following his/her original consult then the repeat service should not be reported.

    If you are using the consultation codes then you would need to follow the guidelines as you would for the initial consultation. Request, reason and report.

    The LCD database number for Medicare is L27484. Depending on the insurance the guidelines for reporting might be different and you may want to check their website (if they have one)

    Hope this helps
    ~Rebecca, CPC, COSC, CPC-I

    "To the world you may be one person, but to one person you may be the world" ~Anonymous

  3. #3
    Kansas City, MO
    Actually, my first question would be what was the referring physicians intent, what did he request? If the referring physician asked for another opinion/consult then it would be a consultation. If however, the referring sent the patient back to treated based on the previous opinion/plan then it is an established E/M. If the patient returned on their own, without being sent to you by the referring, it is an established E/M.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

  4. Default
    I have another meeting to discuss this issue and I want to thank you for your feedback.

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