Neurology & Pain Management Coding Alert

Question: A new neurologist in our office saw an established patient who last appeared in the office two years ago. May I bill a new patient consult for the service? This is a new episode of the same problem the patient had earlier.

New Mexico Subscriber

Answer: Although standard outpatient visits distinguish between new (99201-99205) and established (99211-99215) patients, office consults (99241-99245) require no such distinction. Rather, consults apply to new or established patients.

When determining if you may report a consult, you must demonstrate that you have met the minimum requirements of a request (from the physician sending the patient for the consult), a opinion rendered (by the consulting physician), and a written report (from the consulting physician to the requesting physician) outlining findings, diagnosis(es), treatment recommendations and other relevant information. If you are missing any of these three requirements, you cannot bill for a consult.

If the visit does not meet the requirements of a consult, you should choose an appropriate-level established patient E/M visit (99211-99215). CMS regulations define a "new" patient as one who has not been seen by the physician or physician practice within a three-year period. In your case, another physician in the same practice has seen the patient two years ago, so the patient is "established."
 
Remember: All physicians within the same practice of the same specialty (that is, all physicians sharing the same tax identification number) are "interchangeable" from a billing standpoint.

For example, the patient arrives at your neurology practice complaining of a recurrence of lower-back pain. In this case, the patient has scheduled the appointment at the suggestion of his primary-care physician (PCP), but the PCP did not specifically request in writing a consult from the neurologist. The neurologist provides and documents a level-three E/M service.

In this case, because the patient has been to the office within the past three years, and because you cannot meet the requirements of a consult, you should choose 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).