# new pt vs consult vs established



## 01085585 (Sep 9, 2011)

I need opinions ladies!
How would you code this?
We are a large family practice but now have several specialists (OBGYN, urology, general surgery, etc..) Our NP and PA's and regular MDS often will refer pts to our specialists.. I know Medicare does not pay for consult codes anymore... So when ever our pt sees one of our specialists b/c they have beeen referred my our np would we will a consult code, a new pt E/M since it is the 1st time specialists has seen this pt face to face (but not technically new to clinic), or bill as an established e/m? any input would be great!


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## coachlang3 (Sep 12, 2011)

As far as I can tell the only thing you would have to differentiate between would be if the patients were being sent as a consult or a transfer of care for a specific reason.  The whole new vs. established has gone out the door becasue you are all part of one business/group.

So if the mid-level is sending a pt to one of the group specialists for a professional opinion it would be a consult.


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## MikeEnos (Jan 27, 2012)

*Consult vs New Patient Office Visit*

I'm not sure why you would assume only ladies would respond, but I'll offer my input anyways.  

First of all, I'm going to narrow your choices from 3 down to 2,  Knock established patient off your list because by definition if they the patient is being seen by a patient of a different specialty (even if they are in the same group and within 3 years) then a new patient visit is appropriate.  In your scenario these patients are being referred to a specialist within the group.


*"A new patient is one who
has not received any professional services from the physician or another
physician of the exact same specialty and subspecialty who belongs to the
same group practice, within the past three years."*​
So that leaves you with the option of a consult or a new patient visit, which is the very question I was pondering when I came to this forum today.  I would say that if the insurance accepts consults, and the visit meets the criteria of a consult, then bill a consult.  However if the insurance does not accept consult codes, or the visit does not meet all of the criteria of a consult, then it should be billed as a new patient office visit in your case.

I have a scenario where one of my docs (Neurologist) wants to bill for a consult for a patient he saw, but it seems to me that this is a transfer of care - the PCP referred the patient here for treatment of the condition, not for the Neurologist's opinion so that the PCP could then treat the problem.  The PCP knows that this is something the Neurologist should treat.  Sure enough the Neurologist has scheduled follow up visits for the treatment.  

I think the Neurologist should be billing a new patient office visit.  Do I have the right of it? Or is the doctor right in wanting to bill a consult for the initial visit?  I'm going to need to point to some documentation, and so far I haven't found any to support my view.


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## mhstrauss (Jan 27, 2012)

mikeenos924 said:


> I'm not sure why you would assume only ladies would respond, but I'll offer my input anyways.
> 
> First of all, I'm going to narrow your choices from 3 down to 2,  Knock established patient off your list because by definition if they the patient is being seen by a patient of a different specialty (even if they are in the same group and within 3 years) then a new patient visit is appropriate.  In your scenario these patients are being referred to a specialist within the group.
> 
> ...



This should answer your question; comes directly from the AMA:

"Transfer of care is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility, and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems, though he or she may continue providing care for other condition(s) when appropriate. Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of the site of service."

Here is the link to the entire document, if needed:

http://www.ama-assn.org/resources/doc/cpt/cpt-consultation-services.pdf

So yes, I agree with your opinion that if the specialist knows that he/she will be assuming care for that particular problem, then the new patient codes should be used.  One of the few exceptions would be if additional testing had to be done before the specialist could determine whether or not he/she would treat the problem.

Hope this helps!!


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## MikeEnos (Jan 28, 2012)

That helps a lot, thanks Meagan


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## FTessaBartels (Jan 31, 2012)

*The problem with consults*

The whole problem with consults (as the AMA has defined them in the CPT guidelines), is that whether the visit is a consultation or a new patient visit depends on the *intent of the physician who sent the patient to you*  ... and how the heck are we supposed to know what his/her intent was?

It's pretty clear when a primary care physician sends a patient with a broken wrist to an orthopaedic surgeon, that the PCP expects the Ortho to "take care of this problem."  Ditto when the PCP sends a patient with a hernia to a General Surgeon.

But what about the PCP who sends a patient with headaches to a Neurologist?  Do we *know *the PCP is transferring care?  Couldn't the PCP just be looking for additional expertise in determining the cause and treatment plan for the patient's complaint?  

The CPT guidelines even state that the *consulting *physician *MAY* order diagnostic tests or *institute treatment *for the condition.  SO just because the doctor winds up treating the condition does *not *mean (according to CPT) that the visit was automatically a transfer of care. 

Many "specialists" misused these CPT consultation codes ... and Medicare rightly sought to fix that problem (they were paying more for consultations than new patient visits).  In my humble opinion, the easiest way to fix it would have been to equalize the pay, but instead CMS decided to ignore the code sets.  Now everyone's confused about what to code, and physicians have to be conscious of the patient's insurance coverage in making that decision.  

Okay, off my soap box now ...

F Tessa Bartels, CPC, CEMC


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