Wiki Same practice, Different Specialties: Can you bill for consultation?

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losborn

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I have a PCP who works with a Cardiologist sometimes. The PCP wil "refer" to the Cardiologist (same tax ID) and the Cardiologist will bill for the procedures and a "consultation." There is, of course, the medical record which could serve as the report. But is this appropriate?

Thanks,

Lin
 
You need to make sure that the Cardiologist is set up as a specialist w/the Insurance Company that you are billing. If so, they will pay for the consultation (except Medicare).
 
I wouldn't even bother with consultation codes because Medicare and United Health discontinued these last year and BC/BS followed in December 2010. There may be other payers that are still paying consult codes, but I believe that most have followed Medicare's lead.
 
If I'm not mistaken, I do believe the Cardiologist can bill for a new patient visit so long as he is set up at a specialist with the carriers.
 
The cardiologist (or other specialist) should bill for the consult. Doesn't matter that they have same tax id. If a specialty is not within the scope of practice of the referring physician this is a true referral. Today there are many multi specialty groups billing under the same tax id. As long as the 3rs are satisfied this is truly a consult. The physician must also be set up as a specialist with all insurenace plans. Most multi specialty groups do this.

Most commercial insurers are still paying on consults. They do not pay consults on medicare advanatage plans. In the northeast this includes blue cross and united healthcare. Not to bill a consult is a loss of revenue.

P.s. Billing a new patient code for a specialist in a multi specialty group under the same tax id is a loss of income. If you can bill a new patient then you can certainly bill a consult (again 3 rs need to be satisfied). The only difference is the loss of income for the reimbursement between the two codes.
 
losborn said:
I have a PCP who works with a Cardiologist sometimes. The PCP wil "refer" to the Cardiologist (same tax ID) and the Cardiologist will bill for the procedures and a "consultation." There is, of course, the medical record which could serve as the report. But is this appropriate?

Thanks,

Lin
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Of course the first step is to see if the payer is accepting consults as a valid service.
Second if you can bill as a consult then be sure to have the 3 Rs met. Having the medical record does not satisfy the R requirement for report. It must be a formal dictated letter of consult which is kept in the medical record as well. If it is truely a referral then there is no consult. A referral is where a provider knows what the problem is and does not feel it is in their area of expertise so the patient is "referred" to a provider that can better treat for the condition. A referral cannot be billed as a consult. A consult is where the provider does not know what the problem is and is asking (Request) another specialist for help to provide opinions or answers (Render) to what the problem is and provide the letter of consult (Report) back to the requesting provider which contains all the information on what was found. All 3 Rs must be met for a consult to be billed.
 
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