Practice Management Alert

Question: My physician is being referred patients for -consults- by hospital physicians. When I bill, I am not sure if I should code for a new patient office visit or office consultation. How can I tell the difference?


Oregon Subscriber


Answer: To be able to report a consultation code (99241-99255), there are a few requirements that your physician's visit with the patient must meet. Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:

- Request for opinion

- Rendering of services

- Report to the requesting source.

Last December, CMS added reason to the consultation R-s. Transmittal 788 requires that the requesting physician document the request and the reason for a consult in the patient's medical record.

Important: These are Medicare guidelines only, but private payers generally accept them.

Key point: When the physician visits with a patient and renders an opinion for a requesting physician about a patient's condition and then the patient returns to the requesting physician for treatment, it is usually a consultation.

If your doctor is not asked for his opinion about the patient's problem, and he does not provide his opinion on the patient's status during the encounter, it is not a consult.

Alternative: If you don't meet the consult requirements, and the patient has not seen a physician in your practice within the past three years, you should instead select an appropriate-level new patient E/M visit (99201-99205).

Possible fifth R: Billing and coding experts suggest that you pay attention to a fifth R of consultations: return. Demonstrate that the patient only came to see you about a specific problem and that you-re returning the patient to the requesting physician for the treatment of that problem. You need to show that there is no transfer of care.

The answers to the Reader Questions were provided and/or reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.