Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

new patient vs established patient

Janet Posted Thu 30th of January, 2014 15:15:51 PM

Patient was last seen by our PA on 10/21/11 for diarrhea and abdominal pain. Patient came back on 1/28/14 and saw the doctor for possible gastric outlet obstruction and other gastric issues. I say that it should be coded as established since it hasn't been 3 years since last visit to our office. My doctor thinks it should be consult because patient was referred for evaulation of a new problem. Which one is correct and why? Thanks

SuperCoder Answered Thu 30th of January, 2014 19:40:07 PM

That is established patient. Patient has seen a provider in the same specialty in the same practice within the past three years.

But the consultation codes can be used for new or established patients. Depending on the documentation (request, render, return report), the doctor may be right about billing a consultation. If another provider is seeking your provider's opinion on the patient's problem and sends a return report back to the requesting provider (see consultation requirements), a consult code may be appropriate.

99241-99245 are for "Office consultation for a new or established patient, which requires these 3 key components ...". As indicated in the code descriptor, you can use these even if the patient has been seen in the past three years.

Also, make sure the payer you are billing to still accepts consultation codes, because some payers, such as Medicare, no longer accept 99241-99245.

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

Related Topics