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Established Diagnosis?

Michael Posted Fri 18th of November, 2016 16:19:46 PM
If a patient was referred to a doctor that was in the same group practice and had the same specialty (Dermatology) for a specific diagnosis (i.e., neoplasm) how would you count that diagnosis? The patient would be a consult or established, but would you count the diagnosis as new with additional workup or as an established diagnosis?
SuperCoder Answered Mon 21st of November, 2016 05:53:44 AM

Greetings from!


As per CPT’s guidelines, if the patient has been seen by a physician of the same group practice within the last 3 years, then the patient is an Established patient to all the physicians of that group practice. But when it comes to diagnosis or problem, problems are defined relative to the examiner, not the patient.  Even if the problem was previously known to other physician of that group practice, it is still considered a new problem to another physician if he/she is seeing the patient for the first time or is addressing this problem (e.g. neoplasm) for the first time. This situation arises often in the case on consultations. So if your documentation fulfils the requirements of consultation, then you may code this as consultation, else you should code this as a normal E/M service. Please be sure that Medicare does not pay consultations, so check with other payers too before billing consultations.


Please feel free to write if you have any further questions.




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