01-2014 Case of the Month

What would you do in this this case?

A 23-year-old female is sent to you by her obstetrician/gynecologist for consultation regarding her irregular menstrual cycles, obesity, hirsutism, and insulin resistance. How should you code this visit?

How should you code this visit? 

A. Use a low level established patient code since you are concerned that you might be audited and this will be the easiest to document.
B. Use a new patient code since consultations are no longer recognized.
C. Use a consultation code unless she is a Medicare/Medicaid patient.
D. Wait for the dictation to arrive in your office and have your staff code for the service.


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Answer A is incorrect since by definition, this does not appear to be an established patient.

Answer B would only be correct if this patient were covered by Medicare or Medicaid.

Answer C is correct since you have been asked to provide a consultation by the patient’s gynecologist. Medicare/Medicaid do not cover consultations (they would expect this to be coded as a New Patient encounter), but most third-party payers still cover consultations. It would be important that the Explanation of Benefits (EOBs) be examined closely to make sure the third-party payer reimburses this appropriately. 

Answer D is not correct since the physician is the only one who really knows what the encounter with the patient required and therefore is the most appropriate person to code the claim.

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