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Thread: consult or office vist

  1. #1
    Join Date
    Apr 2007

    Default consult or office vist

    AAPC: Back to School
    I work at an ASC wherE I code for many different types of procedures and one them is pain management. 95% OF the time the codes are mostly straight epidural injections -cpt code 62311- and transformal -64483-64484.
    Now THE Doc that does the pain management usually goes over with me with the codes to make sure we are doing it correct and it matches with his codes for the the physician side. Now here comes my question
    Patient just comes in for a consult and talks to the doc at the ASC
    asc does not bill correct ?
    and what about the physician side, does he use 99241-99244-opr does he use the office visit code 99201-99215
    I never ever code E/M before but I may be doing physician side in futher . PLEASE HELP ANY IDEAS ?

  2. #2


    I don't know if I understand your question. You have 1 ASC physician who was asked for a consult but doesn't do any injections as he usually does. Correct?

    The first issue to verify is: was a consult requested or was the patient referred. Do you have documentation of a consult request? Your Physician can not provide a consult if he was not asked for a consult.

    Second issue to verify: Medicare no longer recognizes the 99241-99245 or the intpatient 99251-99252. Some non-medicare payers have also followed Medicare's lead. So first you have to verify does this patient's payer recognize the consult E&M codes

    If the payer does, then the physician codes and bills for the consult service he provided with 99241-99245

    If the payer does not, then the physician codes and bills based on if the patient is new or est to this provider with 99201-99215. Review the new/est patient rule (same specialty, same group, within last 3 years is an Est patient)

    The physician will code for the E&M service and any procedures he provided. The ASC facility will code for their services.

    If this does not answer all your questions, hopefully you will get some additional responses

  3. #3
    Join Date
    Apr 2007


    Sorry to be confusing-patient was refer by a doctor to this doc to do an injection? Does this make sense ?

  4. #4
    Join Date
    Apr 2007


    I feel that for outpatient pain management ----requests are usually: Evaulate and Treat, especially when the intent of the request is mentioning an injection. I would look for the documentation of the request, the office note itself, and if this office note has the CC at the bottom of it for the requesting and if the note mentions something in regards to who the requesting doctor and reason for their request. Or if there was a letter sent back to the requesting.

    "A consultation is now defined as a service that must be requested by a physician or other appropriate source "to either recommend care for a specific condition or problem or to determine whether to accept responsiblity fo ongoing managment of the patient's entire care or for the care of a specific condition."

    With this new wording that states "or to determine whehter to accept responsibility" this broadens what can be considered a consultation. I would look for added documentation to support that the physician is aware of the intent of the request and his response to that request or extra work such creating a letter back to the requesting. If the additional work is not there, the extra reimbursement that goes with 99241-99245 is not justified.

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