Ophthalmology and Optometry Coding Alert

Some visits are consults in name only.

It happens from time to time – a patient calls requesting a “consult.” But some consultations are consults in name only and don’t meet the criteria to be coded that way. Check out these best practices for consults and referrals to make sure your practice is doing its best in this coding area.

Know Consult History Before You Code

In January 2010, CMS eliminated all consultation codes for office and hospital patient consultations. Many private and commercial insurers quickly followed suit. In place of consultation codes, CMS substituted codes 99201-99205 (Office or other outpatient visit for the evaluation and management of new patient…) for new office patient consultations and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) for established patient office consultations. CPT^® codes 99221-99223 (Initial hospital care, per day…) for initial hospital care and 99231 to 99232 for subsequent hospital care (for lower level consultations) were substituted for in-hospital consultations codes.

However, there are still a few commercial and private carriers that continue to use the old consultation codes — 99241-99245 (Office consultation for a new or established patient…) for office and outpatient consultation codes and 99251-99255 (Inpatient consultation for a new or established patient…) for in-hospital consultations. When using these latter codes and when we consider referrals, transfer of care, and consultations, some coding confusion may continue to exist.

With the removal of consultation codes and the substituting of office and hospital visit codes, transfer of care and “referral” coding problems really no longer exist to any extent. However, since some carriers still use consultation codes as stated above, it’s a good idea to get a quick refresher on how to report them.

Get Comfortable With the Terminology

A “referral” means that one physician asks another physician to take over a patient’s care before the second physician sees the patient and the second physician accepts the patient for a specific condition that needs treatment, according to Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CPC-I, CCS, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COGBC, COSC, program director of Certification Coaching Organization LLC, in Oceanville, New Jersey.

“Referral normally implies that all or a portion of the patient’s care will be transferred to a new provider,” adds Laureen  Jandroep,  CPC,  COC,  CPC-I,  CPPM, founder/CEO of Certification Coaching Organization LLC, in Oceanville, New Jersey.

Important: A referral is called a “transfer of care,” and when your provider treats a patient following such a transfer, it clearly leads you to treating your provider’s evaluation and management (E/M) service as a referral, not a consultation. Usually in these cases one should bill CPT^®  codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...).

Code like this:  Because referrals are a transfer of care, you submit E/M office or inpatient codes to report these services. When referral care takes place in the physician’s office, choose from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...) for new patients and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...) for established patients. Note that these CPT® codes are the same codes that we now use for billing consultation visits in the office.

Seek Out Genuine Consultation Situations

The consultation codes noted above usually have higher reimbursement rates than similar E/M codes for either inpatient or office services. That means you don’t want to miss a consult coding opportunity when it arises — but you also want to have solid justification for coding the consult.

“In the simplest of terms, any consultation, no matter which codes are billed, is a type of service where another physician or nonphysician practitioner requests a doctor’s advice, opinion, or recommendations about a patient’s problem; that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations,” says Jean  Acevedo,  LHRM,  CPC,  CHC,  CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Florida.

Abide by the rules: To correctly code a consult, the documentation must reflect three criteria —requested opinion, rendered service, and reported results to requesting provider. If those are not documented, you cannot bill a consultation.

Caveat: As stated above, Medicare and many other payers no longer recognize the consultation codes 99241-99245 and 99251-99255. For those payers, bill an inpatient or outpatient E/M code just like you would for “regular” E/M services (or for referrals, which use the same codes).