# established vs consult?



## code.holly.willmering (Aug 22, 2011)

Our specialty practice is having a discussion involving established patients who are seen for a new diagnosis.  The physicians believe that a new diagnosis constitutes a new consult visit no matter how long of an interval between visits.  The billing staff would like clarification since the office consultations are for new or established patients.


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## tmerickson (Aug 23, 2011)

Okay, you have two things going on.  First, a consult is defined as a type of evaluation and mamagement service provided by a physician at the request of another physician (verbal or written-must be documented). The consultant's opinionand any services that were ordered must also be documented in the pt's chart, and communicated by written report to the requestiong physician or other appropriate source." _CPT_

Maybe you are using the word "consult" incorreclty?

Second, diagnosis does not matter when it comes to coding a new or est patient. ACOG defines a new patient as "a patient that has not received any professional services from the physician or another physician of the same speciality who belongs to the same group practice, within the past three years."

So, pt not seen in past 3 years by anyone under your tax ID number is new. All others are established.


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## vsprinkle (Aug 24, 2011)

*consult on existing pt.....*



sent to me by someone:
“In regards to the new office consult on an existing patient first the only consideration for a consult code would be for a commercial insurance. The patient would need to be referred for a new problem or to relook at a previous problem the doctor was no longer treating. “



I was under the impression that if a patient has seen a doctor (or someone within the practice) with in the past three years, it doesn't matter if it is a new problem or not, the patient is considered established regardless of insurance. I didn't think a new problem would trigger a consult.



Am I wrong?


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## tmerickson (Aug 24, 2011)

What they have told you is wrong. Medicare does not cover consultation codes, and the other insurance companies are following suite.   My information is directly out of the cpt code book guidelines in the consultation area.  Also, for new patient, I am siteing directly out of the ACOG 2010 E/M coding manual.


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## MnTwins29 (Aug 25, 2011)

*Different specialties?*

Keep in mind that new vs. established also includes specialties.  The original message did not indicate if there were different specialities within this practice.  In order to be new, the pt must not have seen another provider in the same *speciality* within the group in the last 3 years.  

I also agree that it seems like the word "consult" is not used in the practice the same way it is in the coding world.   Is there a request from another doctor for each of these "consults"?


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