Billing an established patient visit as a consultation

Until recently, there was a financial difference between performing a “consultation” and a “new patient visit” for office visits (Medicare stopped paying for consultations at a higher rate than new patient visits in 2010).

In specialists’ offices, patients often got billed for the more expensive “consults” when in fact the visit was not a consultation at all.  Let’s just use this understanding as the brief background for what I’m about to say.

I work at an academic medical center.  My patient base is quite different from that of a typical gastroenterologist in that I often get asked to consult on patients by other gastroenterologists.  Because I see patients from all over the state, patients often come from several hours away and do not expect to get their routine GI care where I work.  Patients frequently return to their referring gastroenterologist for their care after I have rendered my opinion or helped them through their situations.  This is the way tertiary care medicine is supposed to be.  When a patient returns to their gastroenterologist, they are closing the circle of the consultation.

How then should I feel when a referring physician sends me a note on a patient, originally sent to me by him, that says something to the effect of: “John Doe is being seen in consultation at the request of Dr. Ryan Madanick for a history of colon polyps.”

Here are my issues with this:

  1. I didn’t send the patient to him in consultation. I know how to take care of patients with a history of colon polyps. As a matter of fact, I do perform colonoscopy. The patient returned to his care because he was the patient’s referring doctor in the first place, not because I wasn’t certain about the best option for this patient’s care.
  2. The patient is returning to the original referring physician.  The visit shouldn’t even be billed as a new patient visit.  It is an established patient visit (which pays a lot less).
  3. If the patient’s insurance covers consultation codes at a higher billing level, we are all losing (well, except for the payee). The patient probably wouldn’t see any difference. However, if this happens time and time again, the payment system would break down.

Let’s get this straight.  I know the referring doctor well, and I think he practices good medicine.  Still, we know why the note was documented this way.  And this is exactly the type of fraudulent billing practice that got the consultation codes removed by Medicare.

I’ll end by making a plea:  Please don’t bill a patient and their insurance for a consultation when it is just a visit.

Ryan Madanick is a gastroenterologist who blogs at Gut Check.

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  • Terence Ivfmd Lee

    This is a classic example of the problem of having central planning determine pricing. Why should some administrator / bureaucrat get away with decreeing that if Dr. A spends 60 minutes with a “New Patient”, he should be paid a certain amount, but if he spends 60 minutes doing a “Consultation”, he should get paid a different amount? Does the patient truly get different value from a 60-min consultation as opposed to a 60-min “New-Patient visit”? Does this seem silly?

  • Anonymous

    One word…GREED.

  • Jeff Kraakevik

    I’m not even really sure how this would be accepted as a new consultation.  Our billing office tells us that I can only bill as a new or a consult if it’s been over 2 years between visits.  It sounds like this is less than 2 years between visits.  I think part of the trouble is that insurance companies invite it a little on themselves with lack of uniformity in their reimbursement policies.  Thus, the idea that you bill as high as you can with the thought that it will only really get covered by a minority of the insurance groups.  It has the feel of going into the used car sales office, and writing down a ridiculously low number as your initial offer on the off chance that the manager in the other room is feeling generous on that particular day.  I’m not condoning the behavior, I’m just trying to find some reasoning behind this practice.

    Technicalities aside, I agree that this is not really an ethical practice, and I would agree that it is part of why legitimate consultation codes will be billed less.  I also agree with Dr. Lee that they should have moved the billing level of a ‘new’ patient up when Medicare got rid of the consultation code.

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