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Consults and Criteria

  1. #1
    Exclamation Consults and Criteria
    Medical Coding Books
    In an Ophthalomolgy practice where there MD's and ODs/optometrists my question is this:
    Pt comes in for an exam and starts off with the optometrist and the Optometrist does all of the documentatio/testing but does not bill for his visit. pt has cataracts and then is sent down the hall on the same day to see the MD/Ophthalmologist in which he wants to bill a 99244 and use the optometrist as the referral source. I'm having trouble with this and hoping someone can help. I do know that for a consult code it cannot be a split shared visit?. Also the 3 R's.

    thank you,

  2. #2
    This sounds like a referral, not a consult. If the patient was "sent down the hall" with the intent of the Ophthalmologist to take over the care of the patient, this is a referral. If the patient was "sent down the hall" for the Ophthalmologist to give his professional opinion and then return the patient to the Optometrist for treatment, it's a consult. If this is a referral, both providers should be credited with a visit, but neither should use a consult code.

  3. #3
    Why is the OD not charging?

    No, this is not a consult regardless of whether or not the first provider billed for their services or not. This is a transfer of care, the OD is not going to do surgery to remove the cataracts, he expects the MD to do it.

    If they are split/sharing the visit it should be a new or established visit depending on patient status.

    Laura, CPC,CEMC

  4. Default Consults by same practice
    We have the same issue now that a specialist has joined our practice. According to my research on CMS, 'Medicare can pay for a consultation if one physician in a group practice requests a consulation from another physician in the same practice as long as all of the requirements for use of the consultation codes are met'. Further research indicates that the specialist should have expertise in an area that the requesting physician does not have.

    I am online trying to research how to bill. Is there a modifier? The specialist is being denied and we are having to appeal with notes and a letter. Modifier 77?????? We have not been using a modifier for the specialist.

    Thanks for any direction on this issue. We're searching carrier websites and have not located anything yet.


  5. #5
    There is no modifier to get around this if you have 2 providers in the same specialty seeing the same patient on the same day, you will have to appeal these with documentation.

    I wouldn't think this would happen all that often. If this is happening routinely you probably have bigger issues than just getting paid.

    Laura, CPC, CEMC

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