Practice Management Alert

Test your knowledge of confirmatory consultations by answering the billing question below

Physicians often talk loosely about second opinions, but the criteria for billing a second opinion - or confirmatory consultation, as CPT calls the service - are far from loose.

If your physician sees an inpatient to offer his expertise after the patient's treating physician has already stated his opinion, you can choose between two sets of codes to bill the service: initial inpatient consultations (99251-99255) and confirmatory consultations (99271-99275).

Read the following billing question and decide how you would bill in the given scenario. 

Question: My doctor documented that he visited an inpatient whose family and physician had asked for a second opinion regarding persistent heart failure. Based on this documentation, I think I should bill a second- opinion code for the visit. But my doctor wants me to charge for an initial inpatient consultation. What is the most appropriate code?

- Florida Subscriber

Answer: The appropriate code to choose depends entirely on your physician's documentation.

Initial inpatient consultation: To bill an initial inpatient consultation, the medical record must contain documentation of the Three R's: request, render and report. There must be a well-documented "request" for a consultation by the patient's treating physician. Your physician must "render" the consultation by performing and documenting the necessary history, exam and medical decision-making. And finally, your physician must "report" his findings and final opinion back to the requesting physician. If the chart includes documentation of these three consultation requirements,  you should bill an initial inpatient consultation code for the visit, says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

Note: Because you're billing an inpatient consult and the patient's medical record is an ongoing shared record among hospital providers, your physician's "report" would be documented in the shared record. This means you don't have to identify a separate written report for the service to qualify as a consult.

Confirmatory consultation: If the chart doesn't include a documented request for a consultation by the treating physician, and the documentation states that the family asked for a consultation, you should bill a confirmatory consultation code, Brink says. The visit also qualifies as a confirmatory consultation if your physician's notes do not contain formal documentation of a request for a consultation. "A physician consultant providing a confirmatory consultation is expected to provide an opinion and/or advice only," according to CPT.

To bill a confirmatory consultation, your medical chart does not need to contain a request for a consult and you don't necessarily need a written report. You should code any services subsequent to the opinion with the appropriate-level subsequent hospital care code.

Watch out: Carriers don't usually cover second opinions, or confirmatory consultations, unless the payer requests the second opinion. If a third-party payer requires the confirmatory consultation, you should append modifier -32 (Mandated services), CPT states.