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Thread: Consultation versus Established Patient

  1. #1
    Join Date
    Apr 2007

    Default Consultation versus Established Patient

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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
    Join Date
    Apr 2007


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

  4. #4


    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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