AAPC - Back to school
Results 1 to 7 of 7

Thread: Questions of Consultation Billing

  1. #1

    Question Questions of Consultation Billing

    AAPC: Back to School
    Hi, my name is Kathleen from Gastroenterology of Southwest MI. I have several scenario's of which to ask your opinion:

    1) If the primary care sends a patient to us as "consult", and then after our visit, our physician request an colonoscopy for ruling out IBS vs colitis. Our specialist then ask to see the patient in our office for follow up after finding out from the procedure his final diagnosis require more visit to a gastro specialist.
    Would our physician go back and change his original billing from consult to New Patient?

    2) Is follow up in six months an automatic halt to consultation billing to new patient?

    Thanks for your help!

  2. #2
    Join Date
    Apr 2007
    Dallas Texas


    Hi Kathleen,

    In my opinion and past experience, I would go ahead and bill the consult (99241-99244, which is for new or established). If the patient has to follow-up with your gastro in 6 months, then you would bill a regular established patient office visit, since the patient was already seen. The diagnosis would be the only thing that you would change. Per the CPT guidelines, if the pcp refers the patient for another problem, and the documentation supports it, then you can bill another consult visit. Hope this helps.

    Treacie, CPC

  3. #3

    Red face specialist consult's

    That is how we have been doing it, but....isn't when during the consultation visit the plan is to have the patient continue with our specialist, our consult immediately becomes a new patient 99201-99205?

  4. #4
    Join Date
    Apr 2007


    Why would you go back and change an E/M code? They should all stand alone and not be dependent on a service provided later. Also, from my personal experience with gastro, be careful on the consults in general. Many visits termed "consult" are actually transfers of care, especially in gastro. Be sure they are documenting the 4Rs (we teach 4 but I see many people on here saying 3). Request, Reason, Recommendation, and Report. It is the intent of the visit, not the management choice, that determines if it is a consult or just a new. As long as the provider documents appropriately to support the code, you should be fine.

    Laura, CPC

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default CPC Guidelines

    Read the Guidelines in your CPC book.
    2008 CPC Professional Edition, page 14, titled Consultations begins as follows:

    A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.
    A physician consultant may initiate diagnositc and/or therapeutic services at the same or subsequent visit.
    (emphasis added by FTB)

    If the intent of the physician who sent the patient to your specialist was to request a consultation, then that first visit is a consult, EVEN if your specialist determines that additional diagnostic or therapeutic services are warrented. Your specialist's documentation should clearly indicate that Dr X requested a consultation regarding problem Y, should document all the necessary bullets for the level of service (history, exam, MDM), and the report w/ recommendations should be sent to the requesting MD. The recommendations might include ordering an additional test (in your example a colonoscopy) and a follow-up visit to discuss additional management options once the test results are back.

    IF this is what is happening in your practice, the first visit is a consult.
    Any additional visits are established patient visits.

    F Tessa Bartels, CPC, CPC-E/M

  6. #6

    Default Gastro H&P Consults Prior to Scope

    Well, thank you for the info

    I now am trying to figure out if the H&P's consultations our PA is doing with new patients, never seen or not seen in three years, is correct for him to do as incident to?
    I can bill with his ID's for this, can't I though if the payor has credentialed him?

  7. #7
    Join Date
    Apr 2007
    Milwaukee WI

    Default Incident To must be ESTABLISHED patient

    As I understand it, you cannot bill incident to for a new patient. I believe you must have an established patient, with an estabalished problem, and an established plan of treatment.

    F Tessa Bartels, CPC, CPC-E/M

Similar Threads

  1. Consultation billing
    By drwilkins in forum Billing/Reimbursement
    Replies: 3
    Last Post: 04-23-2014, 01:16 PM
  2. Lactation Consultation Billing
    By mputerbaugh in forum Billing/Reimbursement
    Replies: 1
    Last Post: 11-11-2013, 01:41 PM
  3. pathology consultation billing
    By mannlx in forum Billing/Reimbursement
    Replies: 0
    Last Post: 08-18-2010, 06:39 AM
  4. Split visit consultation questions??
    By NIEVESM in forum Family Practice
    Replies: 1
    Last Post: 05-14-2010, 09:10 AM
  5. Billing Family for in office consultation
    By kpennington in forum E/M
    Replies: 3
    Last Post: 04-09-2008, 09:10 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.