Otolaryngology Coding Alert

Question: We saw a new patient, charged for a consult, put tubes in, then returned the patient to the care of his PCP. Six months later, the PCP is requesting that we again see this patient for otitis media. Can we charge for another consult each time we get a new referral from a PCP if it's not for the same problem we treated earlier?

Tennessee Subscriber
Answer: Not only can you bill for another consult in this situation (assuming all the criteria for a consultation are met), you can bill for a consult even if you saw the patient for the same problem, as long as care for the patient regarding the problem remains with the primary care physician (PCP) and all the criteria for a consultation are met, says Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Toms River, N.J.

According to the Medicare Carriers Manual, section 15506, a consultation is distinguished from a visit when:

1. It 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 (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation is documented in the patient's medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.
If these criteria are met, the consultation should be paid unless there is a transfer of care -- which HCFA defines as "when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance."