Selection of
the Proper E/M Code and Documentation of the Required
History and Examination
Once the level of MDM is determined, the
correct E/M code is selected depending on whether the
visit is a consult, new or established patient visit.
New vs
Established
A new patient is one who has not received any
professional services from the physician or another
physician of the same specialty who belongs to the same
group practice, within the past three years. Please note
that the three-year rule does not apply to
consultations. Also, CMS considers Vascular Neurology,
Neuromuscular Medicine and Clinical Neurophysiology as
separate and distinct specialties.
Consultation vs a New Referral
What is the
difference between a Consultation and a New Patient. For
a consultation, remember the 3
R's:
There must be a Requesting
physician who wants you to Render
an opinion and then send a Report.
You can have repeat consultations for the same or
different problem. Consultations do not involve active
management of patient problems although the consultant
may initiate diagnostic and/or the therapeutic services.
If responsibility for ongoing care is assumed,
subsequent services are no longer consultations, but
established visits.
A new patient referral, on the other hand, occurs when
there is the intent of the referring physician to
transfer the total or specific care of a patient to you.
In the case of a new referral, no written letter or
report is required. Once the code is selected, then there is specific
history and exam documentation required for that code (click
on each code below to review the specific documentation
requirements). To see an overview of all the
history and exam documentation requirements,
click here. |