# Questions of Consultation Billing



## kathleenw84 (Nov 3, 2008)

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!


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## treacie smart (Nov 3, 2008)

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


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## kathleenw84 (Nov 3, 2008)

*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?


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## LLovett (Nov 3, 2008)

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


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## FTessaBartels (Nov 3, 2008)

*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


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## kathleenw84 (Nov 3, 2008)

*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?


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## FTessaBartels (Nov 3, 2008)

*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


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