Internal Medicine Coding Alert

Published on Thu Jan 28, 2010 PDF

Question: The internist saw a patient for a preoperative consult before a tumor removal -- how do I bill that now that I hear Medicare will no longer accept consult codes?

Idaho Subscriber

Answer: You are correct -- Medicare's interim fee schedule does not cover consult codes; hence, you can no longer report outpatient consult codes (99241-99245) when the internist consults on a preoperative case.

What to do: Instead, report either new patient (99201-99205) or established patient (99211-99215) office visit codes.

New or established: Interpret the phrase "new patient" to mean a patient who has not received any professional services, that is, an E/M service or other faceto- face service,a from the physician or physician group practice (of the same physician specialty) within the previous three years, according to Medicare.

Example: If you report a professional component of a previous procedure, for instance, a lab interpretation, in a three-year period, this patient remains a new patient for the initial visit. An interpretation of a diagnostic test or reading an x-ray or electrocardiogram without a face-toface service with the patient does not affect the designation of a new patient.

Thus, if your internist provides E/M services that include a detailed exam and an expanded, problemfocused history to a patient that your office has treated in the last three years, report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity) for the encounter.

Necessity is your guide: Don't be confused by volume of documentation -- this is not the primary influence upon the E/M service level. A service's medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code, reports the Medicare Carrier Manual, 100-4 chapter 12, section 30.6.1. Thus, do not report a higher level E/M service when a lower level of service is warranted.