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New Patient vs. Consultation

  1. #1
    Default New Patient vs. Consultation
    Medical Coding Books
    Am I understanding correctly that a new patient equals a transfer of care and a consultation is an opinion/advice regarding management of a specific problem?

    We are an oncology/hematology practice that will often receive referrals from physicians wanting us to evaluate a blood disorder or clear someone who has abnormal labs for surgery. This is from what I understand a consultation and codes 99201-99205 apply.

    But if a patient is referred to us because they have a newly diagnosed cancer and we will be treating the patient and caring for that diagnosis....then it is NOT a consult and new patient codes 99201-99205 apply.

    Am I correct??

    I am new to this and any information you have would be greatly appreciated.

  2. #2
    Central Pittsburgh
    It's not so much why they came to see you, it's the intent of the visit.

    If the requesting physician asks your opinion as he/she doesn't know what course of treatment or a definitive diagnosis, then this could be a consultation. However, if it is clear what the diagnosis is and the MD wants you to handle it and doesn't want to be made aware of the goings on, then it would be a new patient.

    You as the consultant can still order testing, perform services, etc. and it still be considered a consultation.

    It's all about the intent.

    Suzan Hvizdash, CPC, CPC-E/M, CPC-ED

  3. #3

    Does anyone know where I can find this information in writing possibly on the CMS website or aapc website so that I may reference it to my office administrator?

  4. #4
    Default Link to CMS Manual

    30.6.10 - Consultation Services (Codes 99241 - 99255)
    (Rev. 788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)
    A. Consultation Services versus Other Evaluation and Management (E/M) Visits
    Carriers pay for a reasonable and medically necessary consultation service when all of
    the following criteria for the use of a consultation code are met:
    Specifically, a consultation service is distinguished from other evaluation and
    management (E/M) visits because it is provided by a physician or qualified
    nonphysician practitioner (NPP) whose opinion or advice regarding evaluation
    and/or management of a specific problem is requested by another physician or
    other appropriate source. The qualified NPP may perform consultation services
    within the scope of practice and licensure requirements for NPPs in the State in
    which he/she practices. Applicable collaboration and general supervision rules
    apply as well as billing rules;
    A request for a consultation from an appropriate source and the need for
    consultation (i.e., the reason for a consultation service) shall be documented by
    the consultant in the patient's medical record and included in the requesting
    physician or qualified NPP's plan of care in the patient's medical record; and
    After the consultation is provided, the consultant shall prepare a written report of
    his/her findings and recommendations, which shall be provided to the referring
    The intent of a consultation service is that a physician or qualified NPP or other
    appropriate source is asking another physician or qualified NPP for advice, opinion, a
    recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient
    because that individual has expertise in a specific medical area beyond the requesting
    professional's knowledge. Consultations may be billed based on time if the
    counseling/coordination of care constitutes more than 50 percent of the face-to-face
    encounter between the physician or qualified NPP and the patient. The preceding
    requirements (request, evaluation (or counseling/coordination) and written report) shall
    also be met when the consultation is based on time for counseling/coordination.
    A consultation shall not be performed as a split/shared E/M visit.
    B. Consultation Followed by Treatment
    A physician or qualified NPP consultant may initiate diagnostic services and treatment at
    the initial consultation service or subsequent visit. Ongoing management, following the
    initial consultation service by the consultant physician, shall not be reported with
    consultation service codes. These services shall be reported as subsequent visits for the
    appropriate place of service and level of service. Payment for a consultation service shall
    be made regardless of treatment initiation unless a transfer of care occurs.
    Transfer of Care
    A transfer of care occurs when a physician or qualified NPP requests that another
    physician or qualified NPP take over the responsibility for managing the patients'
    complete care for the condition and does not expect to continue treating or caring for the
    patient for that condition.
    When this transfer is arranged, the requesting physician or qualified NPP is not asking for
    an opinion or advice to personally treat this patient and is not expecting to continue
    treating the patient for the condition. The receiving physician or qualified NPP shall
    document this transfer of the patient's care, to his/her service, in the patient's medical
    record or plan of care.
    In a transfer of care the receiving physician or qualified NPP would report the appropriate
    new or established patient visit code according to the place of service and level of service
    performed and shall not report a consultation service.
    Belinda S. Frisch, CPC, CEMC
    Author of "Correct Coding for Medicare, Compliance, and Reimbursement"

  5. #5
    Default remember the "3 R's"

    in order to bill a consult code you must have a REFERRAL from another physician
    This must be documented in the chart and is easiest done by asking for a script to be faxed to you from the referring physicians office along with any pertinent records. The script should say something like "evaluate" or "evaluate and treat" and should include the diagnosis/signs/symptoms/abnormal findings

    Your physician must RENDER the consultation service.

    Your physician must REPLY in writing stating his/her opinion and recomended course of treatment. If your physician ordered any testing he/she should also indicate such in his/her letter.

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