New Patient vs Consultation

Good morning all-

I attended a semiar yesterday and after leaving this semiar, what I "thought" I knew all went out the window.

Can someone please give me the black and white details of the difference between new patients and consults and credable links to print off to figure this out. I am knowing one thing, teaching what I know and then I find out the exact opposite! I am hoping that the speaker mis-spoke and there was a typo! The only thing that is keeping me thinking I know the right way is the other coders are questioning this as well!! LOL

Thanks for your help

You are not alone!!!

This is one of the most confusing areas and I would bet that 90% of billed "consultations" are actually "new patients."

Read this from our CMS intermediary.
http://www.wpsic.com/medicare/part_b/education/consultations.pdf

(Of course when I bill a consultation I KNOW it is correct- the one clearly correct use is when a surgeon refers a patient back to their primary care doc for pre-op evaluation and "clearance." CMS says that should be billed as a consult. {Finally a win for the primary care docs!})

New patient vs Consult

Thank you for your help and it is nice to know that I'm not the only one! I read the link that you have sent me- I want to make sure that I am understanding...

This is a "consult"...

Patient A goes to PCP- he finds she has anemia- he sends her to us-

Our letter to the PCP states- "I was kindly asked by Dr. A to evalulate this very pleasant 25yo female for her anemia" gives the HPI, EXAM and in the mdm he states- we are going to be drawing labs today and I am suggesting that we increase her oral iron intake to...

We decided that she needs to increase the amt of oral iron that she is on, we do some labs and send back our report and findings.

For this to be a new patient- our doctor would have to draw the labs, increase the iron and schedule her for a f/u appt...correct???

And just we have the request, render, report doesn't always make it a consult either then...correct??

Basically- the decision is in the MDM?

Thanks again!!!!

I'll defer to ..

the experts- Nancy? Betsy? Anyone?

new patient/consult

here's the deal. be cautious if you have an established diagnosis. The Consult would be asking an opinion on signs and symptoms (usually). Here you have anemia (suggests labs were alread done). Consider the statement "evaluate and treat", this is a new patient code, not a consultation. Simply put, a consultation is billed when it is the intent of the requesting physician to seek an additional opinion only. If the intent was management of the anemia, you do not have a consult. The decision is in the "WHY" was the patient sent.

new patient/consult

Take a look at the articles in Codapedia on new patients and consults, and the long discussions we've had about it on the forums.

http://www.codapedia.com/~article_55_.cfm

http://www.codapedia.com/~article_47_.cfm
This article has the CMS citation, so you can download and read it for yourself.

I worked with a physician once, who had consults audited by his Medicare carrier and his biggest private payer. All were documented this way, "I had the pleasure of seeing..... Thank you for allowing me to participate in the care." The commercial payer audited them all as new patients. the medicare carrier audited them all as consults. How can we ever explain that?? I say, just say no to pleasure and participation.

Consults require an assessment/opinion/evaluation: what is the best treatment for the patient. Both the requesting and consulting physician may follow up. A transfer of care is: "please take over the care of this patient's pain problem" not "What do you think the best treatment is for this patient's pain." The problem is, the notes are written that clearly.

Anyway, there are articles in Codapedia about consults that you can review.

If you search "consult" there are about 6 or 7 articles.

re: new patient/consult

Thank you all for adding to this thread.

I apologize, but I am still unclear about Consultation vs. Transfer of Care. (This inquiry is based on Non-Medicare/Government insured patients).

As I understand it, Consultation is requesting the opinion on how to treat and the referring provider will then take the information provided by the consultant into consideration, along with their own medical expertise and come up with the treatment and/or options, for the patient.

A Transfer of Care would be when the referring provider basically says, Consult and Treat the patient for the issue at hand, ie: Abdominal pain, sent to general surgeon; general surgeon determines it is a ruptured appendix and takes patient into emergent surgery.

I am under the impression that this would be either a NP or Est pt visit, (99201-99205 or 99212-99215), rather than a consultation as I cannot imagine, anywhere in my mind, that the referring provider is requesting treatment options.

I know I am missing something here because I have also read that a surgeon can consult and treat and still bill the visit as a consultation.

Please help!!!! ASAP Please as I have an education session w/providers soon and need to be crystal clear when I talk with them.

Thank you, in advance for your assistance! ~Dawn Marie