how does a physician report a consultation that is initiated by as new patient?

In the inpatient setting there are two subcategories for inpatient consult codes that are used by physician consultations provided to hospital inpatients, residents of nursing facilities or patient in a partial hospital setting.. The initial inpatient consult codes are used the first time you are asked for your opinion during that hospital stay. You may only report one initial consultation code during the patient's admission for either you or your group partner in the same specialty. If, once you have completed the initial consultation, you assume responsibility for the management of even a portion of the patient's care, all subsequent services are reported using subsequent hospital care codes. Follow-up inpatient consultation codes constitute visits to complete the initial consultation or subsequent consultative visits requested by the attending physician; includes monitoring progress, recommending management modifications or advising on a new plan of care in response to changes in the patient’s status.

Full Answer

What is the difference between an established patient and a consultation?

Therefore, an established patient is one who has received professional services from the physician or another physician in the same group and same specialty within three years prior. Consultation: A consultation is a “type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a

How does the requesting physician use the consultant’s opinion?

The requesting physician utilizes the consultant’s opinion combined with his own professional judgment and other considerations (e.g. patient preferences, other consultations, family concerns, and comorbidities) to provide treatment for the patient.

What is a a consultation report?

A consultation report is generally ordered from a doctor who has referred another doctor to a patient. The consulting doctor is a specialist in an area that the other doctor doesn’t focus on, therefore needing a second opinion on a patient’s situation.

What happens if a patient does not request a consultation?

Patients or a patient’s family may not request a consultation. An evaluation and management (E/M) service “not requested by a physician or other appropriate source … is not reported using the consultation codes but may be reported using the office visit, home service or domiciliary/rest home care codes,” according to CPT ® guidelines.

How do I document a medical consultation?

The entire process of consultation should be documented in the patient's chart: the request for consultation or, in the hospital, an order for the consultation; all physical findings and test results; a clear evaluation and recommendation; the attending physician's evaluation of the consultation and his or her own ...

What is a doctor consultation report?

Consultation reports are used to describe the patient's past history and the reason for being treated with a clear solution as well. The report will let the additional doctor know why the patient is there, in a brief report.

What is the CPT code for new patient consultation?

CPT code 99241: Office consultation for a new or established patient, which requires these 3 components: a problem focused history, a problem focused examination, and straightforward medical decision making.

How do you bill for consultation?

Consultations can only be billed out when requested by another physician or appropriate source.A consultation requested by a patient is not reported by using consultation codes; rather, it is reported by using the appropriate E/M code.

What are the steps in the consultation process?

Outline of StepsStep 1) Define Problem: This ensures that consultants and clients are on the same page and answering the same question.Step 2) Structure the Problem: ... Step 3) Prioritize Issues: ... Step 4) Analysis Plan and Work Plan: ... Step 5) Conduct Analysis: ... Step 6) Synthesize Findings: ... Step 7) Develop Recommendations.

What is the difference between a new patient and a consult?

In most cases, a consultation is a one – time visit. A New Patient Referral usually has an identified problem which requires a specialist to provide care, and does not require that a written report be sent to the requesting physician or health care provider.

What is the difference between 99203 and 99213?

99203 combines the presenting problem (and decision making) of 99213 with the history and physical of 99214. All require four HPI elements except 99213.

Is there a CPT code for consultation?

Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) are still active CPT® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.

What is the difference between CPT code 99213 and 99214?

In a typical 99213 visit, you may not need to review or update the patient's PFSH at all, but a 99214 requires at least one of those areas be reviewed and documented.

What are the 3 R's for consultations?

request, render and replyThe three “R's” of consultation codes: request, render and reply.

What are the 3 key components used to determine a consultation visit?

From an E/M perspective, CPT outlines that all three key components-history, examination, and medical decision making-must be documented for a consultation unless it is determined that time is the controlling factor for the E/M level assignment.

Are consult codes payable?

In 2010 the Centers for Medicare and Medicaid Services stopped paying for consultation codes. While it continued to recognize the concept of consults, it paid for them using new and established patient visit codes (99202 – 99215).

How to check if a new patient is denied?

If a new patient claim is denied, look at the medical record to see if the patient has been seen in the past three years by your group. If so, check to see if the patient was seen by the same provider or a provider of the same specialty. Confirm your findings by checking the NPI website to see if the providers are registered with the same taxonomy ID. If it’s a commercial insurance plan, check with the credentialing department, or call the payer, to see how the provider is registered. If your research doesn’t substantiate the denial, send an appeal.

What is an EKG 93010?

The ED physician orders an electrocardiogram (EKG), which is interpreted by the cardiologist on call. The cardiologist bills 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

How long does it take to determine if a patient is new?

Three-year rule: The general rule to determine if a patient is “new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service. Some payers may have different guidelines, such as using the month of their previous visit, instead of the day.

Why do internists bill established patient codes?

The internist must bill an established patient code because that is what the family practice doctor would have billed.

What does a provider know about a patient's history?

The provider knows (or can quickly obtain from the medical record) the patient’s history to manage their chronic conditions, as well as make medical decisions on new problems. A provider seeing a new patient may not have the benefit of knowing the patient’s history.

What is a new patient?

A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Why are doctors forbidden to tell patients where they are going?

Due to established covenants not to compete, most physicians in this area are forbidden by written contract to tell their patients WHERE they are going. If a former patient shows up at the new practice, they are establishing care with the new practice as a new patient.

What is the code for a follow up inpatient consultation?

If the consultant can’t complete an opinion on the initial consult day, or if the referring physician requests the consultant to return later to provide additional advice, use follow-up inpatient consultation codes (99261-99263) . You must thoroughly document additional consult days.

What is a CMS consult?

The Centers for Medicare and Medicaid Services (CMS) distinguishes consultation services from hospital visit codes, stating that consults are “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.”.

What is a medical record?

The medical record needs to contain documentation of the consultant’s opinion, advice and (if applicable) any services that may have been ordered or performed. CPT guidelines state that a consultant can initiate diagnostic and/or therapeutic services to help formulate an opinion.

Is referral a part of a consultation?

Take a careful look at Medicare’s documentation guidelines, and you’ll find that the answer is “no.” Routine transfer of care or referral is not considered part of a consultation service. It would be appropriate in these situations to refer to the initial hospital visit codes 99221-99223.

Can a physician's request be documented in a plan?

According to Medicare guidelines, in an inpatient setting where the medical record is shared between the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physician’s progress note, an order in the medical record or a specific request for consultation.

What is a consultation in CPT?

CPT ® defines a consultation as “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 other appropriate source.”. To substantiate a consultation service, documentation must include three elements: a request, a reason, and a report.

Why would an ED not report a consult?

In this case, the orthopedist would not report a consult upon seeing the patient because the ED physician isn’t really seeking the orthopedist’s advice or opinion.

What is a consulting physician's report?

In most outpatient settings, the consulting physician’s report (like the consult request and reason) is a separate document sent from one physician to another. In the emergency department (ED) or other outpatient setting in which the medical record is shared between the requesting and consulting physicians (such as a large, ...

What is a cardiologist's job?

The cardiologist performs a diagnostic heart catheter (for instance, 93510 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous ), which showed minimal disease, writes a prescription for the patient, and prepares a letter with findings and recommendations for ongoing care.

Why should same specialty consultations be clarified?

Because same-specialty/practice consultations provide an opportunity for abuse, requesting physicians should clarify in the documentation that the same-specialty/practice consulting physician truly has a skill set the requester does not have.

Does Medicare recognize modifier 32?

Medicare will not recognize modifier 32 for payment, nor will it pay for a second opinion evaluation to satisfy a third-party payer requirement (Medicare Claims Processing Manual, chapter 12, section 30.6.10.D).

Is a medical history report a thank you note?

The report is not a thank you note to the requesting physician for referring the patient, nor is it a courtesy copy of the history and physical. Rather, the report provides instruction to allow the requesting physician to continue treating the patient.

What is a new patient?

new patient is one who has not received professional service from the physician or another physician of the same specialty in the same group within the past 3 years.

What is a consultant in medical?

Consultation services are distinguished from a New Patient because they are performed at the formal request of the attending physician and the consultant provides a report of his/her findings and recommendations to the requesting physician for his/her use in management of the patient’s condition. The purpose of the attending physician’s request must be to obtain an opinion or advice regarding the evaluation and/or management of specific problem(s). A consultant may initiate diagnostic and/or therapeutic services.

What is consultation in medical terms?

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 sources.”

What does it mean when a patient is referred?

Stating that a patient was “referred” means that care was transferred from a referring physician, not that a consultation request was made. After you (as the consultant) have seen the patient “or “rendered” care “you need to “reply” back to the requesting physician. Again, that reply can be a note left in the patient’s chart.

What is the code for a social worker?

If a social worker or therapist asks for your clinical opinion, bill that encounter using one of the initial hospital care codes (99221-99223) . If another physician has already performed a history and physical for the admission, use a subsequent care code (99231-99233). In hospitals, doctors can make a request for a consultation via a note in ...

Is a subsequent visit billed as a new outpatient?

Subsequent visits are reimbursed at much lower rates than consults. The same holds true for outpatient consultation codes. Any documentation oversight could lead to a consult being billed as a new outpatient visit, which carries a much lower work value and reimbursement.

Can a consultation be initiated by a patient?

Documenting “internal medicine” or “blue team” when billing a consult will not suffice. A consultation can’t be initiated by a patient or family member. (Consults can, however, be initiated by a therapist, social worker, lawyer or insurance company.) If a social worker or therapist asks for your clinical opinion, ...

Can a doctor request a consultation?

Requests, rendering and replies. In hospitals, doctors can make a request for a consultation via a note in the patient’s chart. But keep in mind that coders rarely have the opportunity to see the entire chart when billing for a physician’s service.

Do you cross your t and dot your i in a CPT?

It’s important to understand which services are consultations. And when documenting consultations, you need to not only cross your t’s and dot your i’s, but count your “r’s” as well.

Who is Tamra McLain?

Tamra McLain is an independent coding consultant in Southern California. E-mail her your documentation and coding questions at helpucode@yahoo.com, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.

What is telehealth for Medicare?

Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19 – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.

What services does Medicare provide through telehealth?

Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits ( common office visits), mental health counseling and preventive health screenings.

How long does Medicare bill for evaluation?

Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes: 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes.

How do patients communicate with their doctors?

Patients communicate with their doctors without going to the doctor’s office by using online patient portals. Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation.

When will Medicare start paying for telehealth?

Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.

Does Medicare cover telehealth visits?

The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Can Medicare beneficiaries visit their doctor from home?

This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.