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consult coding

Janet Posted Thu 23rd of January, 2014 14:41:20 PM

Pt is new to our office said that she was told her by PCP to see a G.I. doctor but wasn't referred to our office by the PCP. She found our office on her own...would this be considered a consult even though we don't have direct referral from PCP?

SuperCoder Answered Thu 23rd of January, 2014 19:22:31 PM

Hi there.

I would not consider this a consultation because the PCP has not asked your provider for an opinion on the patient's problem and because of that, I wouldn't expect your GI to send a report back to the PCP which completes the requirements of consultation coding.

By definition, according to the CPT Manual, a consult is “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

Therefore, to bill a consultation there should be some sort of notation of a request for an opinion by the other provider. Depending on the payer, it doesn't necessarily have to be a letter from the other provider, but there should at least be a (truthful) note in the record that "Patient is sent by Dr. XYZ for evaluation of abc condition."

Then, there should be a written report back to the requesting physician explaining the findings and the opinion that was requested. Since the PCP didn't request your GI's opinion, I wouldn't expect to see a typical written report back to the PCP.

For these reasons, I wouldn't code this as a consultation, but rather, would use a new patient code. I hope this helps.


Leesa A. Israel, BA, CPC, CUC, CPPM, CMBS
Managing Editor, The Coding Institute
Lead Auditor, TCI Consulting & Revenue Cycle Solutions

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