Ob-Gyn Coding Alert

Question: We have arranged a contract with an infertility specialist. He will be billing services under our tax ID number and is currently set up with the same taxonomy code. Can he bill a consultation from one of our ob-gyn physicians within the same practice or is it an established E/M code?

New Mexico Subscriber

Answer: First of all, Medicare will do away with consultations in 2010, but private payers may not. Many of them do apply Medicare rules which differ from CPT guidelines. Make sure you know the rules that apply before billing.

Yes, he can bill a consultation (99241-99245, Office consultation for a new or established patient ...) provided he meets all of the criteria for billing such. Consider the following criteria:

Either the requesting or receiving physician has documented the request in the patient's record. Both the requesting physician and the consultant clearly indicate the reason for the consultation. This is not a specific CPT guideline, but should be done to ensure you have medical need established for the consultation request. Without this information, a payer may determine that a consultation was not warranted.

The consultant has formed an opinion or an advice. The consultant reports the information back to the requesting physician.