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Ophthalmology and Optometry Coding Alert

Reader Question:

Handle Same-Day In-House Consults

Published on Mon Aug 18, 2003

Question: Our practice includes 10 ophthalmologists. Some of them have areas of specialty, like glaucoma. If one of our doctors is conducting an exam and asks for a consult from one of the other doctors in the practice, and the second doctor conducts diagnostic services that day, can I bill all of this for the same date? How should I code this?

Florida subscriber

Answer: The answer is yes - and no, depending on the reason the ophthalmologist is seeing the patient for a consultation.

If the second physician in the group practice sees the patient for the same reason on the same day, the Medicare Carriers Manual (MCM) instructs you to submit one bill that combines the services of both physicians. "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems." 

Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. (Refer to 15511, Prolonged Services, when the duration of the direct face-to-face contact between the physician and the patient exceeds the typical time of the visit code billed.)

If the consultation is for an unrelated problem, you should follow the following steps to bill for the service:

Step 1: Code the original appointment as an E/M service. Select a code from the ranges 99201-99205 or 99211-99215, or eye codes 92002-92004 or 92012-92014, depending on whether the patient was new or established. The level of E/M service will depend on the qualifying level of the key components and any contributing factors.

Step 2: Code the E/M service provided by the consulting physician. CPT defines this as an "Office or Other Outpatient Consultation," so you'll use a code from 99241-99245, depending, again, on the level of service delivered according to the key factors. The codes for outpatient consultations do not distinguish between new and established patients. You should code this separately.

Remember the rules for consults, and guard against relaxing these simply because your doctors have the convenience of being in the same office within earshot. Make sure that you collect all of the required documentation between the doctors to establish the consultative relationship. These include the Three R's:
 

  •  Request: A consult is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.
     
  •  Reason: A request for a consultation from an appropriate source and the need for consultation (medical necessity) must be documented in the medical record.
     
  •  Response: After the consultation, the consultant must prepare a written report of his or her findings that is provided to the referring physician. MCM guidelines specify that the consultation report must be "a separate document communicated to the requesting physician."

    Step 3: Code for the "consulting" physician's diagnostic service. Again, the date is not an issue. CPT guidelines state: "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." However, you do have reporting rules to deal with in this case. To correctly report the services of the consulting physician, keep this CPT direction in mind: "Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of the initial consultation should be reported separately."

     - Clinical and coding expertise for You Be the Coder and Reader Questions provided by Raequell Duran, president, Practice Solutions, Santa Barbara, Calif; Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company; and Teresa Thompson, CPC, an independent allergy coding and reimbursement specialist in Sequim, Wash.

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