Neurosurgery Coding Alert

Question: May I bill a consult for an established patient (last seen two years ago) seen by a new surgeon in our office? 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 both new and 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 reason (medical necessity), and a written report (from the consulting physician to the requesting physician) outlining findings, diagnosis(es), treatment recommendations and other relevant information. If the visit does not meet these three requirements, you cannot bill for a consult.

In such situations, 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 this case, another physician in the same practice saw the patient two years ago, so the patient is "established."

Remember: All physicians within the same practice (that is, all physicians sharing the same group provider number) are "interchangeable" from a billing standpoint.