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Thread: Consultations Visits in Outpatient Hospital

  1. #1

    Default Consultations Visits in Outpatient Hospital

    AAPC: Back to School
    Ok, I have a patient that is Medicare, outpatient/observation, is seen by my physician for an initial consult on day one. Patient has been in our office before and within the past three years. Because patient is in hospital for a new reason or illness can I bill a consult code as new patient or do I still need to use established consult code? For instance, with Medicare, if patient is a new consult level three, then we bill 99203, if established we use 99214. I have been lead to believe that if our doctor is seeing a patient in the hospital for a new reason, even though they have been a patient within the past three yrs, we can bill the consult codes used for outpatient new. Can anyone give me some feedback on this? I was under the impression even if it is a new reason such as chest pain, our consult has to reflect established patient? Thank you, Gail, CPC

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Inpatient vs Outpatient

    Since Medicare no longer recognizes the consultation codes we are instructed to code services which previously were consults as follows:

    First visit by the provider for each hospitalization is coded using Initial Hospital Visit codes 99221-99223

    OUTpatient (includes ER, Observation, Clinic, Office)
    In the ER you can use the ER codes.
    For all other outpatient areas the "consulting" physcian will use
    1) NEW patient (hasn't been seen in more than 3 years) - new patient codes 99201-99205
    2) ESTABLISHED patient (HAS been seen within last 3 years) - established patient codes 99211-99215

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3


    So if the consulting provider sees the patient on day 2 in observation, would you then bill 99224-99226???
    Dawn Smith, CPC

  4. #4
    Join Date
    Apr 2007
    Hartford, CT


    No, only the provider who placed the patient into observation status can bill 99224-99226 (at least per NGS J-13 policy). The "consulting" provider would have to bill POS outpatient and in this case since pt is established, use E/M codes 99211-99215. Your best bet is to check with your local Medicare contractor for their particular guidelines.

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