# Outpatient Consultation



## tcoder5 (Mar 11, 2014)

Can you bill a consultation (99241-99245) for an established non-Medicare patient if they have been seen within 3 years?


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## arauch (Mar 11, 2014)

Codes 99241-99245 are defined in the 2014 AMA CPT book as being for "new or established patient". I believe this can be interpreted to mean you use this same code range wether the patient is new OR established. I would just be sure that your visit meets the "consultation" criteria and definition of being initiated by a provider requesting an opinion, and that that information is documented. See CPT definition for Consultations.


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## MarcusM (Mar 11, 2014)

http://emuniversity.com/OfficeConsuls.html
"A consult is provided by a physician whose opinion or advice is requested by another physician about a specific clinical problem or issue.  Consultations may also be requested by nurse practitioners or physician assistants.  The name of the requesting clinician and the reason for the consultation must be recorded in the chart.  The results and recommendations of the consult must be sent to the requesting physician."         The last sentence is important to be considered a consultation.....


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## bforr (Jun 20, 2014)

I'm asking this question as a patient, not a coder: I'm a type 1 diabetic, and I called a new endocrinologist to establish care. I did not have a referral, I just called to set an appointment. My claim on UHC's website shows a consult. I am going to call UHC to see what CPT code was billed. Can this provider bill a consult when I, the patient, initiated contact with no referral?


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## mhstrauss (Jun 20, 2014)

bforr said:


> I'm asking this question as a patient, not a coder: I'm a type 1 diabetic, and I called a new endocrinologist to establish care. I did not have a referral, I just called to set an appointment. My claim on UHC's website shows a consult. I am going to call UHC to see what CPT code was billed. Can this provider bill a consult when I, the patient, initiated contact with no referral?



No.  If there was no other provider requesting the Consult, that voids it straight off.  Should have been a New Patient visit (as long as you've never seen any provider in the clinic/specialty in the previous three years).  I would definitely dispute the charge!


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## MarcusM (Jun 20, 2014)

Definitely not a consultation so you are correct to investigate.


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## bforr (Jun 20, 2014)

I called UHC on break, and sure enough they billed 99244. I will be calling the office to ask them to try again. Thank you for the input.


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## Texascoder64 (Jun 22, 2014)

*Consult code within same specialty group*

In a specialty office setting, for example, Dermatology, that bills all under the same tax id#, can 1 physician or PA refer to the Mohs surgeon in the group and the Mohs surgeon bill a Consult code appropriately since there is only 1 Mohs surgeon and the referring general derm is recommending the patient to see the Mohs surgeon for a consultation prior to scheduling Mohs surgery. 

Want to make sure this scenario would be supported in an appeal vs. billing an established level e/m. My thought is that the general derm is not a mohs surgeon and if the patient has a specific need to see the Mohs surgeon in the group, then would the visit coded as a consult 99242-99244 be appropriate?


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