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Consult vs. New Patient

  1. #1
    Default Consult vs. New Patient
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    When a physician refers a patient to our general surgeon's office for a consult and our physician ends up doing surgery at a later date, do we charge a Consult or a New Patient code? Our doctor does types up a report for the requestion physician and a copy is maintained in our patient's medical record.


  2. #2
    Johnson City
    In our General Surgery practice we rarely bill for Consultations. To constitute a consult the referred to doctor must not assume the care of that patient for the specific problem, instead of treating the problem the referred to doctor is suppose give their opinion to the requesting physician on how they should go about treating the patient. That is almost never the case for us the surgeon will take the patient to surgery and treat the problem, therefore they assume the care for that specific problem. So the patient is new on the initial visit, not a consult.

    There is also other criteria for consult billing a request, and written letter back must be documented too.

    I hope this helps.
    Melissa Jewett, CPC

  3. #3
    I have never heard that the doctor can't assume care for the problem for a consult.

    Per my 2010 cpt

    ...a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.

  4. #4
    Greeley, Colorado
    The CPT definition of consultation codes changed 1/1/10 (as you stated in the above post) so technically you can code a consult. Prior to 2010 it would not be a consult if they assumed care.
    Lisa Bledsoe, CPC, CPMA

  5. Default
    A consultant can initiate treatment.


  6. #6
    I'm confused, are we supposed to be using the consult codes in 2010?

  7. Default
    Quote Originally Posted by Zina View Post
    I'm confused, are we supposed to be using the consult codes in 2010?
    The Medicare & Medicare Advantage plans no longer pay for consults. But most of the other carriers still do at this time.


  8. #8
    Milwaukee WI
    Default It Depends
    The Surgeon MAY be performing a consultation or may be evaluating a new patient. It depends on why the original physician sent the patient to you.

    Example: Internist believes he has discovered a hernia when examining patient. He sends patient to general surgeon to determine treatment options.
    This is a consultation ... even if the surgeon determines that surgery is warranted and schedules the patient for same right away.

    Example: Internist sends 55-yr-old patient to a gastroenterologist to have a screening colonoscopy. This is a new patient. The patient was sent to the specialist specifically to have the procedure done.

    This is all a very gray area. Medicare decided that the way to deal with it was to no longer recognize the consult codes. Some state Medicaid carriers are following Medicare guidelines.

    The way Mjewett's office has chosen to deal with this is not wrong, but there are patients who receive consultations from surgeons.

    F Tessa Bartels, CPC, CEMC

  9. #9
    Default multiple IPconsults, same patient, different stays
    More consult questions for 2009 services.

    Sorry, a little confused on this one. Our cardiologist was asked to see an IP for a specific problem. He saw her, charged a consult, provided followup treatment (IP) for the problem and then charged a subsequent visit for the next day. The patient was then discharged, but then readmitted 13 days later for a different problem.

    Our cardiologist, who had only seen the patient as IP, never in the office, was called in for another consult, same patient, different problem. Again, he charged a consult, and billed for his PC component of tests he ordered. Pt was discharged next day.

    Patient is admitted again, 16 days later, different dx (4 dx, none of the previous dx). Patient has not been seen in the office. The cardiologist is called for a consult AGAIN and sees the pt, orders tests.

    3 consults, 3 different admissions, 3 sets of dx., patient has never been seen in the office.

    The question is, should the initial visits for the 2nd admission and 3rd admission be billed as consults, or is the patient now considered an established patient (keep in mind, this is '09)?

    Please help! The cardiologist would like to be reimbursed! Thanks, all for any info you can offer.

  10. #10
    Milwaukee WI
    Default It's possible
    Lizz B ...

    The cardiologist MAY have been consulted multiple times over a period of several weeks or months for different issues all on the same patient. You will need proof IN WRITING from the requesting physician that s/he was actually seeking a consultation ... i.e. advice or opinion on how THAT provider should manage the issue, VS transfering the care of the patient to the cardiologist for management of the issue(s). Obviously, the cardiologist's report back to the requesting physician will be required, as well.

    It makes no difference if the patient had been seen in your office or not.

    Hope that helps you.

    F Tessa Bartels, CPC, CEMC

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