# Physician consult for an established patient



## Tonyj (Sep 11, 2014)

Can we bill an inpatient consult (MCR 9922X) of an established pt if we are not the admitting physicians?


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## AR2728 (Sep 11, 2014)

Assuming this is a commercial payer that accepts consults and not Medicare, you can bill an established patient for a consultation for a new issue if all consult requirements have been met.  You can not bill a consult on an established patient for a diagnosis you were already treating/following.


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## ChristieH (Sep 11, 2014)

AR2728, so let's say pt has Aetna, and we have been treating him via infusion therapy in our office on a daily basis but condition worsens and he is admitted to hospital by a hospitalist.  The hospitalist asks us to consult and our doc sees the pt and also follows him in the hospital. Would our doc not be able to charge a consult (9925x or MCR 9922x) because we have already been treating this patient in our office for an infection?  Thanks for your opinion on this question.


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## Tonyj (Sep 12, 2014)

AR2728 said:


> Assuming this is a commercial payer that accepts consults and not Medicare, you can bill an established patient for a consultation for a new issue if all consult requirements have been met.  You can not bill a consult on an established patient for a diagnosis you were already treating/following.



The pt was admitted by his endocrinologist for diabetic services. We were asked to consult for his Hem/Onc condition. The pt is an established pt of ours (Hem/Onc) with Medicare (9922x). 

I feel I should know this answer as a yes but I'm second guessing myself.


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## mitchellde (Sep 12, 2014)

Tonyj said:


> The pt was admitted by his endocrinologist for diabetic services. We were asked to consult for his Hem/Onc condition. The pt is an established pt of ours (Hem/Onc) with Medicare (9922x).
> 
> I feel I should know this answer as a yes but I'm second guessing myself.


No this is not a consult.  The endo provider knows that your provider treats the patient for the hem/onc condition and has requested that your provider continue to follow this condition while  inpatient, therefore you use subsequent inpatient codes.
ChristieH -  this is the same answer for your question.  The hospitalist admits your patient and requests your provider to continue to follow the same condition you were treating prior to the admit; this is not a consult and must be billed with subsequent encounter codes


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## Tonyj (Sep 12, 2014)

mitchellde said:


> No this is not a consult.  The endo provider knows that your provider treats the patient for the hem/onc condition and has requested that your provider continue to follow this condition while  inpatient, therefore you use subsequent inpatient codes.
> ChristieH -  this is the same answer for your question.  The hospitalist admits your patient and requests your provider to continue to follow the same condition you were treating prior to the admit; this is not a consult and must be billed with subsequent encounter codes



Thanks Debra


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## ChristieH (Sep 15, 2014)

Thank you Debra.


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## ChristieH (Sep 15, 2014)

Debra, I have another question. When my ID doc is following a pt in the hospital and performs a f/u visit (9923x) and pt is discharged by the attending on the same day...many times the pt leaves hosp and comes to our office the same day to begin daily IV infusions for an infection. The docs f/u visit (9923x) on that day is always denied because the pt also came to our office that day after leaving hosp to begin treatment. My doc feels he should be paid for that hosp visit. We've tried modifiers on occasion as well and still don't get paid. Do you know the rationale or another way we should bill this for my doc to be pd for services he performed?  Thank you again for your help.


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## mitchellde (Sep 15, 2014)

You would need to use a 25 on the hospital visit and be sure the POS is 21 and then bill the infusion as a POS 11.  If the hospital visit documentation is all about setting up the infusions and referencing the infection then you have not met the criteria for the 25 modifier and you cannot bill both


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## ChristieH (Sep 15, 2014)

Debra, I will give it a try.  I actually have this issue currently sitting on my desk, so have appended the 25 and fingers crossed.  Thank you for your help.


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