1. What is the difference in a follow-up consult in the hospital and a subsequent hospital care?
A: As of January 01, 2006 there are no longer follow-up consultation codes (99261 – 99263). For follow-up consultation in the hospital see the subsequent hospital care codes (99231-999233).
Subsequent hospital care includes reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status since the last assessment by the physician.
2. How often can I bill for an office consultation?
A: Generally speaking there is a 3-year rule for consultations in the office based on the new vs. established patient rules. 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. There are no follow-up consultation codes in the office so all subsequent visits should be billed as established patient office codes.
However, if an additional request for an opinion or advice regarding the same or a new problem is received from the attending physician and documented in the medical record, the office consultation codes may be used again.
3. Patient is seen in the hospital as a consult. Two weeks later patient continues as an out-patient. Will patient be considered new patient or established?
A: Patient is considered an established patient.
4. In a rural area, where there is a lack of primary care physicians, a patient requests consult. Does this count as new patient or consult? You see the patient regarding his chief complaint, and never use follow-up.
A: New Patient is appropriate if the patient is self-referred in all areas. Chief complaint if for follow-up should include “follow-up for _________”
5. A patient is seen as a hospital consult. She is seen again on a separate admission 3 mos. later. Is this a new consult?
A: Assuming the criteria for a consultation is met, yes.
6. How do you code and respond to a consultation requested by a nurse practitioner or a PA? Should letter go to the primary care MD that they work under?
A: The letter can be sent to either the NP/PA or doctor as long as the provider has a Medicare provider number.
7. A patient wants a second opinion. Can that be a consult? Even though she is self-referred?
A: Second opinions are no longer billed under a separate set of codes, and 99271-99275 confirmatory consultations have been deleted as of January 01, 2006. If a request is made by another physician, then it can be billed as a consultation. If the request is made by the patient, then see the appropriate E/M service code for the setting and type of service.
8. Can you bill for office staff time (not RN) for patient education such as nutrition? If so, what CPT code and what documentation?
A: No.
9. Patient is seen as a new initial inpatient consult; the patient is then seen in the office for the same problem as a post-hospital visit. No follow-up care was arranged but the primary care physician sent the patient for an office appointment. How should this be billed?
A: If all criteria for consultation are met, bill an outpatient consultation.
10. An orthopedic surgeon requests a pre-op evaluation of a patient. Is this covered under global surgery rules and/or how do I code for this?
A: A routine pre-operative exams performed by the surgeon, after the decision to perform surgery is made, are considered part of the global package and are bundled into the surgical fee. However, if the patient is seen by another physician pre- and post-op, and there is medical necessity, then the evaluation should be separately paid and billed with modifier -56.
A surgeon will often request that a patient's primary care physician examine the patient prior to surgery. For example: A patient with a history of heart disease is scheduled for surgery but the surgeon wants the patient's regular cardiologist to examine him prior to the procedure. This should be billed using the appropriate office/outpatient consult code, because the cardiologist's opinion is being sought by the surgeon.
To bill for these visits you would code the appropriate E&M service, along with the ICD-9 "V" pre-op exam codes V72.81-V72.84 as the primary diagnosis, then the code appropriate to the problem requiring surgery as secondary. Also, you should list relevant diagnoses for pre-existing conditions. You shouldn't have a problem getting paid for these consults since the primary care physician isn't limited by the surgical procedure's global period.
11. In an outpatient setting, is follow-up established, the same as follow-up consult? Also, is in-patient?
A: There are no codes for outpatient follow-up consultation. If the visit qualifies as a consultation it is billed as such regardless of patient status. If the visit is for an established patient and does not qualify as a consultation it should be billed as an established patient visit. The inpatient setting does have codes for a follow-up consultation which may be billed if the physician is returning to evaluate the patient for second request by another provider during the same stay, or if the initial consult required additional information for which the physician is returning on a second day to interpret and recommend treatment. Otherwise the visit is a subsequent hospital visit.
