Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 01, 2008 PDF

Details on diagnosis, treatment can help you light the way

If CPT's many revisions to the consult coding language still have your head spinning, we've got the cure. Check out this primer to ensure you're billing consults and office visits accurately.

The history: In 2006, CMS redefined a transfer of care as one that occurs "when a physician or qualified NPP [nonphysician practitioner] requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition."

The revision caused confusion over whether cases in which a specialist sees a patient at the request of a physician for care of a specific condition could qualify as a consult.

Solution: The answer is "yes" if the requesting physician is asking for your practitioner's opinion regarding the patient's condition, diagnosis or treatment, says Heather Corcoran with CGH Billing in Louisville, Ky.

Recommended documentation indicates a request for opinion or advice regarding a specifically stated problem or symptom, says Jay Neal, an Atlanta-based coding consultant.

Example: A primary-care physician (PCP) sends a patient to a pulmonologist for an evaluation. Does the initial visit's request qualify as a consult?

The answer depends on what the PCP is asking for in his request to the pulmonologist.

The visit can qualify as a consultation if the PCP knows the condition and is asking for the pulmonologist's opinion relative to an appropriate treatment plan.

Example 1: The PCP's request states, "Patient wheezing indicates that he may suffer from asthma. Please provide further workup, as well as your opinion on possible treatment options."

In this case, the patient's treatment hasn't been confirmed as the appropriate plan of care. Therefore, the pulmonologist is truly rendering an opinion. If the initial encounter meets the other consultation criteria, including a report back to the PCP, you may code the visit with 99241-99245 (Office consultation for a new or established patient ...).

Best practice: The physician can stress that he rendered an opinion by using "requesting" terminology in his report. A good "requesting" statement would be along the lines of, "Thank you for requesting my opinion on treating Patient X's persistent cough."

Requests specifying the treatment may fall short of a consultation.

Example 2: The PCP's request indicates, "I am sending to you an emphysema patient who needs further testing and treatment for the condition." The request doesn't meet a consultation's intent for opinion. Instead, the report is a transfer of care for a specific condition.

Therefore, you would code an office visit (99201-99215, Office or other outpatient visit ..., depending on whether the patient was new or established).

CMS guidelines state that the consulting practitioners "may initiate diagnostic services and treatment at the initial consultation service or subsequent visit."

"CMS specifically says that Medicare will pay for a consult whether or not you initiate treatment on the date of service, assuming you meet all of the consultation requirements and a transfer of care does not occur," says consultant Andrea Pritchard of New Orleans.

However, if you take on the patient and continue to see him or her on a regular basis, you'll instead report the subsequent office visit codes (99211-99215).