By Emily Hill, PA-C

This article appeared in the March 2000 issue of CNS News

Many of the services provided in a physician's office involve a history, physical exam, and subsequent decisions regarding the plan of care. In CPT, these services are described as Evaluation and Management Services (E/M). The various E/M codes reflect the necessary physician work required for the type of service, place of service, and the patient's status.

What's the Difference Between New Patient Services and Consultations

One of the distinctions that poses difficulties for the average physician practice is that between new patient services and consultations. Let's start with the easiest definition to understand: new patient encounters.

By CPT definition, a new patient is one who has not received any professional services within the past 3 years from either you or your colleague of the same specialty in your group practice. The new patient definition applies only to the category of E/M Services titled "Office or Other Outpatient Services". These patients are typically self-referred or have been sent by another health care provider for treatment. The theory used to distinguish between a new patient and an established one is that the new patient requires more work. It is easier to assess the situation of an established patient because you are familiar with the patient's history and general medical findings. However, if you have not seen an established patient within the past 3 years, according to CPT, you would assess the patient as a new patient.

Consultations are unique services in the sense that you have been asked for and are delivering an opinion. Patients you see in consultation may be either new patients or established patients to your practice. There are four types of consultations: outpatient, initial inpatient, follow-up inpatient, and confirmatory.

The criteria for the use of consultation codes are met if:

Your opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or appropriate source;
• The request and need for the consultation is documented in the patient's medical record;
• You prepare a written report of your findings, including any services ordered or performed, and provide it to the requesting health care provider.

Revisions were made by CPT 2000 and Medicare to the category of consult codes to clarify their appropriate use. These revisions clarify that:

Both verbal and written requests for the consult are acceptable as long as the request is documented in the medical record by either the requestor or the consultant;
• A consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit and still report a consultation code for the initial encounter (assuming all requirements are met);
• A written report of the findings must be communicated back to the requestor.

When Do You Use Consultation Codes?

Suppose you are asked by another physician to evaluate a patient's seizure disorder. The patient has been on a stable regimen of anticonvulsive agents for several years but recently has had breakthrough seizures. Because of your expertise in the area, you are asked to see the patient in your office and provide advice regarding management options. At this visit, you evaluate the patient and possibly recommend changes in medication or other aspects of the patient's treatment plan. As a consultant, you may initiate the medication change and/or order diagnostic studies at this visit. If you also asked the patient to return for follow-up, then the next visit with the patient would be reported using established outpatient codes.

Let's suppose the requesting physician asked you to take responsibility for the treatment of the patient's seizure disorder prior to sending him/her to your office. In this case, you are not a consultant as the care of the patient has been transferred to you in advance. You would report this initial service using either a new or established patient E/M code according to the above definition of a new patient.

Another possible scenario is that you saw the patient in consultation for the first visit and returned him/her to the requesting physician with recommendations for continuing management. At some point thereafter you are requested once more by the physician to re-evaluate the patient's condition and treatment plan. This visit would again be reported using the outpatient consultation codes assuming all the requirements of a consultation are met.

What About Inpatient Consults?

The guidelines that define a consult are the same for outpatient and inpatient services. In the inpatient setting however, there are two subcategories for inpatient consult codes. The initial inpatient consult codes are used the first time you are asked for your opinion during that hospital stay. You may only report one initial consultation code during the patient's admission for either you or your group partner in the same specialty. If, once you have completed the initial consultation, you assume responsibility for the management of even a portion of the patient's care, all subsequent services are reported using subsequent hospital care codes.

There are two instances in which you use follow-up inpatient consultation codes:

The visit is necessary to complete the initial consultation;
• The attending physician requests subsequent consultative services.

The latter instance assumes you only provided an opinion or advice at the first visit and did not subsequently manage any of the patient's care.

Who Else Can Request a Consultation?

A confirmatory consultation is different because it may be requested by the patient, the family, or even a third-party payer. A confirmatory consultation is also different in that you can only provide an opinion and/or advice on previously recommended treatment. In other words, you cannot initiate care or make changes to medication and/or previous treatment.

What are the Documentation Requirements for Consultations?

Like all E/M services, the level of service must be supported by the documentation in the medical record. The AMA/HCFA Documentation Guidelines provide direction for the requirements based on the extent of the history, examination, medical decision making, and in some instances, time spent with the patient.

In the case of consultations, the request and need for the consultation and a written report of the findings must be documented in the patient's medical record. In the August, 1999 Medicare Carriers Manual, more specific guidelines were provided to address the circumstances of a shared medical record in an emergency department or an inpatient or outpatient setting in which both the requesting and consulting physicians have access to a single medical record.

Medical Record Shared by Requester and Consultant

The request may be documented as part of a plan recorded in the progress note, an order in the medical record, or a specific written request for the consultation.

The report may consist of an appropriate entry in the common medical record.

Office Setting Without Benefit of Shared Record by Requester and Consultant

The request may be documented by a specific written request from the referring physician or a specific reference by the consultant.

The report must be a separate document communicated to the requesting physician.

Why Use Consultation Codes?

Both CPT and HCFA instruct the coder to select the most specific code for the service performed. Choosing consultation codes, when appropriate, meets that directive. In addition, and equally important for the average practice, is the fact that consultation codes typically reimburse better than most other categories of services. The difference in reimbursement obviously depends on the type and level of service provided as well as the payer.

Understanding and staying current with coding and reimbursement rules is certainly not easy. Working as a team, physicians and their staffs can assure that coding is done properly, thereby improving reimbursement and avoiding allegations of false claims. Next month, we'll take a look at coding for critical care services and the associated documentation requirements.