Pulmonology Coding Alert

Question: I know that CPT deleted the confirmatory consult codes for billing second opinions, but I'm not sure how we should report these services now. Can you advise me how I should bill our pulmonologist's work performing a second opinion?


Illinois Subscriber

Answer: If a patient presents to your practice and requests a second opinion, you should report the appropriate E/M office visit code (99201-99205 for new patients, 99212-99215 for established patients). Because most second-opinion requests are patient-generated, you should treat these office visits as you would any other
E/M visit.

Caveat: In many cases, the term "second opinion" is misunderstood. Physicians may also request a specialist to provide a second opinion, and coders should consider this a true consultation. Report consultation codes when the requirements for consultation are met (requested by another healthcare provider involved in the patient's care; assessment rendered; report of findings provided to the requesting provider). 

Otherwise, a more appropriate set of codes is reported. According to CMS Transmittal 788, dated Dec. 20, 2005, "In a facility setting, a second-opinion consultation arranged through the attending physician shall be reported by a physician/qualified NPP using an appropriate initial inpatient consultation code [99251-99255] when the consultation requirements are met. When consultation requirements are not met, the subsequent hospital care codes (99231-99233) in the hospital setting and the subsequent NF care codes (99307-99310) in the NF setting shall be reported," the transmittal says.

This policy applies to outpatient consultations (99241-99245) as well. If a primary-care physician needs the pulmonologist to evaluate the patient and confirm his diagnosis and treatment plan, the pulmonologist may report a consultation as long as all of the consult requirements are met.

If not, report the appropriate new (99201-99205) or established patient (99212-99215) code.