Internal Medicine Coding Alert
Could a New Problem Be a Consult Opportunity?
Question: A patient originally came to our office based on a referral for a procedure. The internist subsequently sees the patient for a problem that the procedure manifested. May I report a consult for the subsequent visit? Answer: You should code this service as an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) or as subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...), depending on the setting.
Maryland Subscriber
Because the subsequent visit is for managing the patient's condition, you should not consider it a consult.
Exception: If the referring physician requests the subsequent consult visit, the encounter may qualify as a consultation (99241-99255). The patient's medical record should contain documentation of the request for opinion, rendering of findings, and report to the requesting physician.
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