Multiple Outpatient Consults Are Possible
A physician may report more than one outpatient consult for the same patient. The subsequent visit, however, must meet all the consultation service criteria to bill it as such, according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.C. Subsequent visits not meeting the consultation service requirements should be reported using the appropriate inpatient or established outpatient E/M service code. The Claims Processing Manual reiterates, “If the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.”
For example, a primary care physician (PCP) examines an established patient and diagnoses a breast mass. The PCP sends the patient to a general surgeon for advice. The general surgeon examines the patient and recommends a breast biopsy. The surgeon schedules the biopsy and sends a written report of his recommendations to the requesting physician. The general surgeon subsequently performs the biopsy, and continues to see the patient on a yearly basis for follow-up. Following the advice and intervention by the surgeon, the PCP resumes the patient’s general medical care.In this case, the initial visit with the general surgeon meets all the requirements of an outpatient consultation, and may be reported as such (eg, 99242). Subsequent visits provided by the surgeon, however, should be billed as an established patient visit in the office or other outpatient setting (99211-99215), as appropriate.
In a second example, the patient from the previous example visits her PCP some months later with a new complaint of lower abdominal pain. The PCP requests a consult from the same general surgeon. In this case, as long as the visit for abdominal pain meets all the consultation requirements, the general surgeon may report another consultation service, as appropriate to the documented service level provided.