Medicare Compliance & Reimbursement

Know when you can report a repeat consultation -- and when you can't If you're a specialist and you use the three-year rule across the board for outpatient services, you're sacrificing consultation pay. After you send a patient back to the primary-care physician (PCP) for a completed episode of care, you can perform another consultation. "The three-year rule applies to office visits, not consultations," said Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, in The Coding Institute's Otolaryngology Coding and Reimbursement Conference in San Antonio. Know Status With 99201-99215 You should use the same code for office consultations (99241-99245, Office consultation for a new or established patient ...) regardless of the patient's status as new or established. In contrast, CPT splits office visit codes into those for new patients (99201-99205, Office or other outpatient visit for the E/M of a new patient ...) and those for established patients (99211-99215, Office or other outpatient visit for the E/M of an established patient ...). E/M service guidelines consider a patient new when, within the past three years, she has not received any face-to-face service from the physician that he reported with a CPT code or from another same-specialty physician within the same group practice. Zero In on Different Issue If a physician requests your specialist's opinion on a patient's new problem, you can code another consultation, regardless of how much time has transpired between issues. Suppose the patient comes in for a consult for central vertigo (386.2). Your physician treats the patient for that specific problem and then sends the patient back to her PCP. A year later when the PCP sends the patient in for a consult from the specialist on a nasal hematoma (920) and epistaxis (784.7), "we would charge out a consult," says Candice Ruffing, CPC, with Drs. Berghash and Lanza PL in Florida. Key: Look at the diagnosis to see whether you're treating the patient for a new problem or the same problem. Try your skill with the following cases. Compare Problems in Requests An internist requests a specialist's opinion on the cause and possible treatment of a patient's chronic sinusitis (473.9), which the internist has tried unsuccessfully to treat several times. At this encounter, the specialist performs an E/M and scope (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) and issues a report on his findings (473.8, Pan-sinusitis) to the internist. Catch: The specialist performed radical neck dissection (RND) on the patient nine months ago, and the patient is scheduled for an annual cancer check visit with the surgeon in three months. The specialist charged 99244 (... requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity ...) [...]