Pulmonology Coding Alert

Question: A patient was visiting a primary care physician (PCP) for a persistent cough. The physician referred him to our office after failure of treatment options. Is this a new patient visit or a consultation?

Nevada Subscriber

Answer: It is not a straightforward decision. If the case passes the following criteria then you can safely code it as a consultation: 

1. The first criterion is that a consultation (99241-99245, Office consultation for a new or established patient …) must be at the direct request of another physician or qualified healthcare provider (e.g., nurse practitioner) involved in the patient’s care. Your case satisfies this condition as the PCP referred the case and requested the consult from your pulmonologist. The pulmonologist should ensure it is documented in the patient’s medical record that the visit is a consultation at the request of Dr. X. Another way to document the request is through the communication sent back to the requesting physician (see #3 below). 

2. The second issue pertains to the intent of the visit. The PCP may want to hand over the case completely to the pulmonologist as he feels that the care of this problem should be provided by the pulmonologist only. In such a case, where there is a transfer of care prior to the visit with the pulmonologist, you should code the visit as a new patient visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient…). If the PCP has sent the patient just for the pulmonologist’s opinion on how to manage the patient, and the patient will continue further treatment with the PCP, it is a consultation. In conjunction with reporting of the consultation codes (99241-99245), the pulmonologist may initiate treatment for the persistent cough and authorize a follow-up visit to evaluate the response to treatment. You will code the follow-up as an established patient visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient…). 

3. The pulmonologist must make sure that the opinion sought by the PCP is communicated back to him. The pulmonologist can send a letter back to the requesting physician saying, “Thank you for allowing me to see your patient in consultation for persistent cough or I had the pleasure of seeing your patient in consultation for persistent cough,” and then outlining the recommendations for care. 

If you think you have fulfilled all these requirements, you can confidently bill the visit as a consultation. Otherwise, code it as a new patient visit.