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Consultation versus Established Patient

  1. #1
    Default Consultation versus Established Patient
    Medical Coding Books
    If a patient was seen in 2009 for a vasectomy and returns in 2011 for scrotal pain and perineal pain, according to documentation the PCP referred the patient and this is a new problem for this patient. Is this a consult or an established patient visit? Does it matter what insurance is being billed?

  2. #2
    Milwaukee WI
    Default Referred means established
    If the patient is referred to you for care of the problem he is an established patient.

    If the PCP sent the patient to you with a request for your opinion on how the PCP should manage the problem, it is a consult.

    If the patient is covered by MediCARE you cannot bill a consultation code in either case, because Medicare does not recognize the consultation codes.

    If the patient is covered by MedicAID or commercial insurance you will need to check with the payer to see if they are following MediCARE rules on consultation codes. A few commercial carriers have announced they will also follow MediCARE re consults.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    I thought there was a 3 Year rule, I would consider the patient established, but yea I would check with the payer

  4. Default
    there is a 3 yr rule, the pt was seen in 2009 and 2011 by the same provider, it does not matter that it is a new problem

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