Internal Medicine Coding Alert

Question: A patient has insurance coverage that requires her to go to her primary-care physician (PCP) for referral to all specialists. This patient was seen by an ob/gyn for pregnancy-related care and needs to be referred to a specialist for a test. The patient had never been seen in our office, so she had to establish with us in order to get the necessary PCP referral. Our physician didn't do any exam because the ob/gyn already did it. How should I code this visit? ICD-9 code V68.81 seems to apply. If I use this code, can I use 99212 for the CPT code? I thought I had to use well-visit codes with V codes. Because the doctor didn't do a physical, I can't use those codes.

Maryland Subscriber

Answer: V68.81 (Encounters for administrative purposes; referral of patient without examination or treatment) is an appropriate ICD-9 code for the scenario you describe. Because the patient's insurance company requires the patient to "establish" with the PCP prior to a referral to a specialist, the visit should be covered with this diagnosis.

Select your CPT code based on the key components: history, exam and medical decision-making (MDM). It appears from the information you provided that only two of the key elements of an E/M visit history and medical decision-making were met. The physician had to determine whether it was appropriate to refer the patient to a specialist, but no treatment was rendered. Therefore, the MDM level appears to be straightforward.

Assuming that the physician obtained at least a focused history, 99212 would be appropriate. Because this physician chose not to perform even a minimal exam, you cannot code a new patient visit. All three of the key components history, exam and MDM must be documented in order to use the E/M codes for new patients (99201-99205). A preventive care code also would not be appropriate because a comprehensive exam was not performed.