Orthopedic Coding Alert

Question: Should I report a consult for an established patient (whom we last saw two years ago) if a new physician in our office sees him? 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. Consultation codes apply to both new and established patients.

You may report a consult if you meet the minimum consultation requirements: a request from the physician who sent the patient for the consult, a review of the patient's condition (your exam), and a written report (from your office to the requesting physician) that describes your findings, diagnosis(es), treatment recommendations and other relevant information. If the visit does not meet these three requirements, don't choose a consultation code.

Instead, choose an appropriate-level established patient E/M visit (99211-99215). CPT defines a "new" patient as someone whom your practice has not seen within a three-year period. Because another physician in your practice saw the patient two years ago, CPT considers the patient "established."

Remember: All physicians of the same specialty within the same practice (that is, all orthopedists sharing the same group provider number) are "interchangeable" for billing.