E&M consultation levels


North Haven, CT
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I recently had a discussion with a certified coder that did some reviews of consultation codes for my company. She allowed 99243 with the following key components: history comprehensive, exam expanded problem focused, MDM of low complexity. I would have thought that since all 3 key components were not met that the code should be 99242. She said she had an AMA graph tool that showed an end result of 99243 because the history exceeded the required level for 99243. I am unfamiliar with that "tool". Comments? Also, would you allow a consultation code just because the doctor sent a letter to the primary physician describing what he did and thanking him for the referral even if there is no evidence of his "need to know"?

These are not Medicare claims. CPT(AMA) rules apply.
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If the insurance you are billing the claim to is Medicare, the information you were given is incorrect. Medicare requires that your Medical Decision Making MUST meet the requirements for the code billed. You can't take a history and up-code based upon that. You are required to show medical necessity for the code you are billing. All elements must be met.
Consult vs referral

To answer your second question, No, I wouldn't allow a consult bill just because the physician sent a courtesy letter to the PMD thanking him for the referral.

The intent of the visit must be for CONSULTATION - ADVICE and RECOMMENDATION.

If you show up at your PMD's office with a cut on your face and he says, "I don't take care of that; you need to see Dr Plastic Surgeon," the PMD is NOT requesting a consult ... he's just referring the patient to the specialist to be taken care of.

If you show up at your PMD's office with a mole and he says, "Let's ask Dr Plastic Surgeon to take a look at this and see what he recommends," then the PMD is asking for a consultation. The Plastic Surgeon may wind up removing the lesion and later further treating the patient to deal with scarring as a result of the surgery, but the intent was for a consult, and so the first visit with the Plastic Surgeon would be a consult.

F Tessa Bartels, CPC-E/M