Dermatology Coding Alert

Published on Wed Feb 16, 2005 PDF

Dermatologists often face denials when they perform a consult and provide treatment on the same day, but you should append modifier -25 for these services and fight denials when necessary. Consider this scenario:

A family practice physician asks a dermatologist to consult on a patient with a severe rash. The dermatologist reviews the patient's history and examines her. The dermatologist makes an initial diagnosis of nonspecified contact dermatitis (692.9, Contact dermatitis, NOS).

Next step: After thorough examination, the dermatologist applies patch tests on the same day and asks the patient to return in 48, 72 and 96 hours for readings.

You should report 95044 (Patch or application test[s] [specify number of tests]) because the dermatologist applied the patch tests, coding experts say.

You should also bill for the E/M services the dermatologist provides to the patient, says Pam Biffle, CPC, CCS-P ACS-DE, a dermatology coding consultant in Bellevue, Wash. You should determine the most appropriate E/M code (99201-99215) to report based on the scope of the examination and the key components the dermatologist covers with the patient.

Don't forget: You have to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to your E/M code to notify the payer that the dermatologist performed an initial evaluation that led him to complete patch testing on this patient. The insurer rejects the injection charge because the payer doesn't reimburse for consult and treatment on the same date.

"Usually the denial happens the other way around: The consult is denied as bundled with the treatment code even when a modifier -25 is used," says Sandi Hamrick, CPC, coder at a private practice in Ohio. "It sounds like this particular insurer is not following CPT guidelines, which most certainly allow for a consult and treatment to be billed, but is instead following its own rules."

Solution: The practice should appeal the denial with copies of documentation from CPT, Hamrick says. CPT states that you should separately report any specifically identifiable procedure (identified with a specific CPT code) performed on or subsequent to the date of the initial consultation.

Carriers Want to See the Request

Always make sure that the dermatologist documents the request for a consultation in the patient's record, whether the initial request is verbal or written.

Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the requesting physician's office and at your office.

When your dermatologist reports back to the requesting physician after a consult, you should avoid the word "refer." Instead of saying, "Thank you for referring John Doe to me ...," the dermatologist should write, "Thank you for your request to render a consultation ..."

'Request' Rules Differ for Confirmatory Consults

You should report "A 'consultation' initiated by a patient and/or family, and not requested by a physician" using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient), according to CPT. And you can code for these consults when an insurer or third party seeks a second or third opinion.

CPT says that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."

New/established: You can use 99271-99275 for new or established patients when the patient wants a second opinion and when an insurer requests a specialist's opinion. The dermatologist can provide confirmatory consults in any setting.

If an insurer requires the consult to determine  medical necessity prior to covering a procedure or service, report the appropriate code and append modifier -32 (Mandated services).