# Consultation vs new patient?



## lisademarco517@gmail.com (Jan 7, 2015)

My Dr. is an allergist.
A patient was sent over from another Physician for an allergy evaluation.  A paper referral is not required by his insurance company.  What are the criteria for billing this out as a new patient vs consultation?    Rarely do we see a patient one time and discharge from practice.  They are usually seen every few months to monitor allergies/asthma.   thank you.


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## lstaniscia (Jan 7, 2015)

I used to bill consult codes for anyone who was referred by another physician and new patient for any self referred.
I was told recently by a supervisor that if you only see the patient once  you should bill a consult but if you take over care (for the condition for which patient was referred ) than you can bill new patient. Doctor still has to report back to the referring physician.


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## Reenie98 (Jan 7, 2015)

I agree with the previous post. If the problem has been diagnosed; and the patient is referred for treatment, a new patient code is appropriate. However, if a patient is referred for "sinus symptoms"; and the physician does a work up and finds it to be allergies; and asks the patient to return for treatment; it would be OK to bill a consult. The key is how the referral comes over; are they being referred for treatment, or is their a request for an opinion on the patient's heath.


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## lisademarco517@gmail.com (Jan 8, 2015)

thank you


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## CatchTheWind (Jan 8, 2015)

Which payers are you billing consult codes to?  (I was not aware of any that still pay these.)


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## lisademarco517@gmail.com (Jan 8, 2015)

So what if a patient sees a doctor for suspected "allergies" based on certain symptoms? No formal/written referral but PCP mentioned they should see allergist. They go to provider directory, find us and call. We see the patient and schedule follow-up testing to diagnose the specific allergy causing the problem and recommend therapy. Most of the time we follow them afterwards.

Do we need a written referral to bill out consult? Does it need to be documented somewhere that another physician recommended the evaluation? If we plan to continue to follow them for a specific condition, can it still be a consult code?


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## lisademarco517@gmail.com (Jan 8, 2015)

Medicare does not pay - other carriers do.


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## Reenie98 (Jan 8, 2015)

Only Medicare has said they will not pay for consult codes. This will include your Medicare replacement plans. In some states Medicaid will follow this...so I would check with your carrier. But Commercial Insurances (IE; Aetna,Blue Cross and Blue Shield, Med Mutual, UHC[again unless they are a Medicare Replacement ]) will still pay the consultation codes.


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## Reenie98 (Jan 8, 2015)

lisademarco517@gmail.com said:


> So what if a patient sees a doctor for suspected "allergies" based on certain symptoms? No formal/written referral but PCP mentioned they should see allergist. They go to provider directory, find us and call. We see the patient and schedule follow-up testing to diagnose the specific allergy causing the problem and recommend therapy. Most of the time we follow them afterwards.
> 
> Do we need a written referral to bill out consult? Does it need to be documented somewhere that another physician recommended the evaluation? If we plan to continue to follow them for a specific condition, can it still be a consult code?



In order to bill a *formal request for consultation MUST be present in the medical record* If a patient comes in because their Dr mentions that they should see an allergist...and they get your name from a friend or carrier...and make an appt. And they do not present with an order for consultation...you should bill it as a new patient. Best practice is to have a formal written referral in the chart. The referral should state something like..."referring for TX of allergies" or referring for "consultation and treatment of chronic sinus issues" [these are examples...not the only options]. The referral should set the ground work for determining if the patient is being referred for treatment of an established problem...or requires work up...and your physician to render an opinion prior to treatment. There is no reason a consult can not be billed even if the patient returns for treatment...but it all goes back to the reason the patient was referred.

Hope this helps!


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## lisademarco517@gmail.com (Jan 8, 2015)

thank you.


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## lisademarco517@gmail.com (Jan 8, 2015)

That is helpful. However, I do not understand the concept of treatment of an "established problem" and what it has to do with a consultation. Rhinitis, sinusitis and asthma are easy diagnoses to make and PCPs attempt to treat. We then see the patients with refractory symptoms despite therapy tried by the PCP. It is similar to a physician that sees an endocrinologist for uncontrolled diabetes. The endocrinologist is seeing the patient for an already established diagnosis.


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## Reenie98 (Jan 8, 2015)

That is the distinction the referral must make. If the patient has a known condition and the referral is simply for treatment of that condition...then a consult will not be billed. Diabetes and asthma are known conditions. If the patient is sent to a specialist because the physician can't manage the disease...it is a transfer of care; and a consult should not be billed. ( unless the physician asks the specialist to see the patient...and give the referring Dr recommendations for treatment; but in this case...the patient will be seen once in your office, then transferred back to the referring physician)

Rhinitis for example may have other causes...such as allergies...and may require work up before treatment. 

Just be diligent about scrutinizing the order that comes over...and don't be afraid to ask the referring Dr for clarification ( I have worked in family medicine for 18 years...I promise we don't mind) . The order should really specify what the referring dr is expecting out of the referral. A transfer of care, a consult, or a consultation followed by treatment. 

The bottom line is consult codes kind of have a bad rep...and can be a little scary to bill...but if you have supporting documentation there is no reason not to bill them. 

In our practices we see a lot of specialty offices creating forms. They ask for pt demo information; some history and testing info..and most importantly they have check boxes outlining transfer of care, consult...ect. We fill it out and fax it over...and the specialist sets up the appt. That way they get everything they need from a front office standpoint; and a clearly documented order for billing purposes; maybe you should think about trying something similar.


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## lisademarco517@gmail.com (Jan 9, 2015)

Thanks.. Would you email a copy of this form to me?  Just for a starting reference if you have some time.  It's lisademarco517@gmail.com.   Appreciate your help!!


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## cathy@eyebillforyou.com (May 15, 2015)

*Still Billing Consults Here in Maryland*

Just went through a day of ICD-10 training by a well-known highly respected coding trainer for the AAO.  She said she doesn't know why anyone is still billing consult codes.  My physician still lists them for us to post and from what I can see we are getting paid from commercial payers pretty regularly.  Occasionally they recode them to a corresponding E/M code vs Consult.  We are in Maryland and take almost all insurances.  I am interested in others experience in this area.


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## krwheato (Mar 26, 2016)

*report*

What is considered to be acceptable as the report portion of a consult? I have doctors that will state thank you for letting me see patient for said diagnosis, and send copies to the requesting doctor?


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## CodingKing (Mar 26, 2016)

krwheato said:


> What is considered to be acceptable as the report portion of a consult? I have doctors that will state thank you for letting me see patient for said diagnosis, and send copies to the requesting doctor?



A written report of the consultant's findings and opinion or recommendation is communicated back to the requesting practitioner.


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