New patient VS Consultation

HELP HELP!!! Can someone please explain the difference between the two other than the statement "Thank you for the kind referral...." I know that new pt is when they are taking over the care of the patient, but does that mean ENTIRELY and the other physician will no longer be seeing the patient?

Thanks for all your help!!!

Consultations

A consultation is a service rendered by a physician or non-physician practitioner with an area of expertise not possessed by the requesting physician. A consultation must meet the following criteria:

•It is requested by another physician/provider.

•This request is documented by the requesting physician/provider.

•The consultant communicates their findings, impressions and recommendations back to the requestor.

The purpose of a consultation is to obtain the guidance and recommendations regarding the diagnosis, evaluation and/or treatment.

A transfer of care (typically new patient) occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.

In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.


Categories

Office Outpatient Consultations (Codes: 99241 through 99245). Office consultations do not distinguish between new or established patients. The codes are used to report consultations provided in a provider's office, emergency department, outpatient clinic of a hospital, ambulatory facility, and observation area of a hospital.

Coding Guidelines

• If during the course of the initial encounter you determine that you will assume care of the patient this initial visit can still be billed as a consult.

• Follow up visits by the consulting provider should be reported using the appropriate office or subsequent hospital visit codes.

• If subsequent to the initial consultation an additional request for an opinion or advice is requested from the attending provider and it’s documented in the medical record, an office consultation may again be billed. This is applicable whether treating the same or a new medical condition.

Example: A family practice physician requests a consultation regarding a patient’s chronic shoulder pain. The consultant examines the patient and forwards their opinion to the family practice physician. No surgical intervention is indicated at this time. Several months later the patient’s condition is exacerbated, and the family practice physician once again asks that you consult on the patient. This patient encounter may be billed as an office and other outpatient consultation.

• In an office setting documentation within the medical record must reflect a request by the attending physician. This can be documented in the body of the requesting physician’s note, or in a letter or form requesting consultation. The consultant must also specifically reference the request within their documentation.

Example requesting: I have asked Dr. Miller to consult on Mrs. Jones regarding her chronic back pain and limited range of motion…..

Example consultant: Mrs. Jones presents today at the request of Dr. Smith regarding her chronic back pain and limited range of motion…

• It is acceptable for one physician in a group practice to request a consultation from another physician within the same practice as long as the documentation requirements of a consultation are met.

• A consultant may initiate diagnostic and/or therapeutic services.

• The consultant’s opinion and any services that were ordered and/or performed must be documented in the patient’s medical record.

Initial Inpatient Consultations (Codes: 99251 through 99255). These codes are to be used when a consultation is performed in a hospital inpatient setting or nursing facility.

If a consultant subsequently assumes responsibility for management of a portion or all of the patient’s condition(s), consultation codes should not be used from that point – use subsequent hospital care codes.

Coding Guidelines

• Only one inpatient consultation may be billed per consultant per hospital stay.

• In an inpatient setting, the requirement of documenting the request for an opinion and/or advice may be documented as part of a plan written in the hospital record, or by a specific written request for consultation.

• In an inpatient setting, the consultant’s opinion/advice back to the requesting provider may consist of an appropriate entry in the common medical record. No cc: is required.

• It is appropriate for one physician in a group practice to request a consultation from another physician within the same practice as long as the documentation requirements of a consultation are met.

• The consultant’s opinion and any services that were ordered and/or performed must be documented in the patient’s medical record.

• For Follow-up inpatient consults, see subsequent hospital care codes (99231- 99233) or subsequent nursing facility care codes (99307-99310).

New patient VS consultation

This is always one of the most spirited discussions.

I have a few suggestions: read the section in the Medicare Claims Processing Manual that discusses the definition of a consult for yourself. You can find that citation in the article I referenced below.

Read how others have interpreted consults, after you've done that.


This is a discussion of consults and transfer of care:
http://www.codapedia.com/~article_47_.cfm

If you search on consult, consultations, consults in the Codapedia data base, you'll find quite a few articles to review.

This is a nightmare

for specialists. As a primary care doc, 99% of the time I send patients to specialists to fix the patient's problem, not to tell me how to fix them. How am I supposed to set a fracture or do a colonoscopy or perform a cholecystectomy??? So technically that is a New Patient for the specialists not a consultation. But I am sure they bill a consultation. They do document "referred by Dr. X" and they send me a note.

No great answers in figuring this one out from me.

consults

I'm a general surgeon, and although I'm frequently asked to "see" patients and perform operations, I don't consider myself a technician. I don't perform tracheostomies just because a pulmonologist requested this. I always evaluate the patient first, give my opinion as to how best to treat the patient, and then if necessary I will perform the surgery. Therefore, I consider most of these consultations. I don't know if that meets the requirements but that's how I interpret the rules.

Consults

I think there is just enough gray in the definition to give us all gray hair!

Definitely not consults:
*Sent from the ED to your office. ED doctor doesn't want an opinion, is transferring care
*Standing orders (All patients admitted to ICU must have consult from XX service, by hospital policy)
*Sent from another physician of your specialty in another geographic area. Patient seen in Florida by Neurologist, sent to Neurologist in NY to resume care after spending summer in Florida.
*Self referred patient

New patient VS Consults

Thank you so much for your responses! It is very hard to get this across to the docs and if for some reason they don't put the "Thank you for referring..." statement in there, then you have to hunt and search the chart for any correspondence stating they were asked to see this patient for this particular problem...UGH!!! As a Hem-Onc office, I don't come across many new patients, the new patients we have are the "snow-birds"- those that travel south for the winter and then come back in the summer and need to establish care for their issue BUT then it is still a new patient if you read the docs notes! Such a fine line and I struggle with it! I miss the days where the new patient was the self-referred, you remember....walk in off the street days!!!
Well thank you again for you help!!!