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New patient or Consult

  1. #1
    Question New patient or Consult
    Exam Training Packages
    New patient or Consult

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    One of the neurologists that I work for has started her own practice. Although she is still in our office and renting her room, she has her own TIN and provider ID's. Her NPI is the same. My question is, if the patient is already established with her in our office, will the first visit to her with her own 'company' be considered a consult? She insists since she has her own TIN, these first visits with her are consults. "It would be like I moved across the street." I think, at least, they should be new patient. She knows the patient & history. We haven't divided the charts from one practice to her practice. This all very confusing especially since she has no real contract with the owner of the practice & his consultant yet. Still in negotiations. I really need some help fast. I really don't want to get in any trouble or audited.

  2. #2
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Quote Originally Posted by sky View Post
    New patient or Consult

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    One of the neurologists that I work for has started her own practice. Although she is still in our office and renting her room, she has her own TIN and provider ID's. Her NPI is the same. My question is, if the patient is already established with her in our office, will the first visit to her with her own 'company' be considered a consult? She insists since she has her own TIN, these first visits with her are consults. "It would be like I moved across the street." I think, at least, they should be new patient. She knows the patient & history. We haven't divided the charts from one practice to her practice. This all very confusing especially since she has no real contract with the owner of the practice & his consultant yet. Still in negotiations. I really need some help fast. I really don't want to get in any trouble or audited.
    Since she has already seen these patients, they are neither consults nor new patients if they see her again - they are established patients. It doesn't matter if she moves down the hall or across town, changes TIN and provider ID's - if she saw the patient in the last three years, they are established.

    Hope this helps!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  3. #3
    Location
    Evansville Indiana
    Posts
    451
    Default consults
    Lucinda is completely correct. These are established patients. The only way that I could see a consult being charged is if a non-Medicare patient's physician requests an opinion on a new problem.

  4. #4
    Location
    Jacksonville, FL River City Chapter
    Posts
    74
    Default
    Seeing a patient in the past three years does NOT prevent coding a consult for the patient.

    You actually have two questions to answer, in this order:

    • Can the service be coded as a consult based on CPT rules and allowances?
    • If the service can NOT be coded as a consult, should the visit be coded as a "new" vs. "established" patient visit?


    The answer to the first question is that she CAN code some visits with patients of the "old" group/specialty as consults, as long as the service meets the definition of a consult. Here's the kicker. Even if she were to be seeing patients in the "old" group/specialty, she could bill a consult sent from another provider in the same group/specialty if the service meets the definition of a consult (like one neurologist in the practice asking another for an opinion because of the second provider's strength in sleep medicine).

    CPT said in the 4/2000 CPT Assistant:

    CPT does not limit the use of the consultation codes according to whether or not the physician providing the consult service is of a different specialty field than the physician requesting the advice or opinion. The guidelines for use of the consultation codes simply indicate that use of these codes requires that one physician is responding to a specific request for opinion/advice from another physician regarding evaluation and/or management of a specific problem. Therefore, if the physicians are of the same specialty field and the guideline information regarding use of the consult codes is met, a consultation service code may be reported.

    So first decide if the service meets the definition of a consult. If NOT, only then will you need to decide if the "normal" E/M visit should be coded as a "new" vs. "established" patient. Once you get to this point, she can NOT call all patients new just because she is billing under a different tax id number. She can only call them new if she did not see them in the previous three years.

    CPT said in the June 1999 CPT Assistant:

    What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?

    If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.


    Hope this helps.

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