Answer: There are two questions to be answered here. First, is this a consultation or a visit? And second, is this a new or established patient?
Medicare clarified the three criteria for consultations in the Medicare Carriers Manual, Section B3-15506:
1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.
2. A request for consultation is documented in the patient's medical record.
3. After the consultation is provided, the consultant prepares a written report of his or her findings. CPT 2002 states, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source." Consultation codes (office 99241-99245, inpatient 99251-99255) are used for both new and established patients if the consultation criteria are met as outlined above.
If a "consultation" is initiated by a patient and/or family and not requested by a physician, it is not reported using the consultation codes but may be reported using the codes for confirmatory consultation (99271-99275) or office visits (99201-99215), as appropriate.
In the situation posed by the reader, the first decision to make is whether this is actually a consultation. Was there a documented request by another physician for an opinion about this patient's breast mass? If so, then this is probably a consultation and should be coded as such. If there was not a request for consultation or if the patient initiated this visit herself, this should be coded as an office visit.
You must then determine if this is a new patient or an established patient. CPT 2002 states that a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. An established patient is one who has received services within the past three years. This patient, seen 18 months ago by the same physician, even though for a different problem, is an established patient.
