Wiki How should I code a New Patient Visit with a general surgeon for a nexplanon removal?

[theisel@lakeviewclinic.com]

EDIT: Changed Consult to New Patient.

Our general surgeon saw a New patient for evaluation of a surgical removal of Nexplanon (the new patient visit in an office setting), significant attempts were made for removal before the patient was referred to us. Is it appropriate to use the Z30.46 (encounter for surveillance of implantable subdermal contraceptive) as the primary diagnosis?

The patient is going to need surgery in the hospital to remove the device.

 

[CBLENNIE]

It doesn't sound like this is a true consultation billed with CPT codes 99242-99245, it sounds like the patient was referred to the general surgeon to assume care for the removal of the Nexplanon because the referring provider was unsuccessful in their attempts to remove the implant. Many commercial insurance companies followed Medicare and stopped covering the consultation E&M CPT codes 99242-99245 (outpatient) and 99252-99255 (inpatient) and will only reimburse for office/outpatient E&M codes 99202-99205 & 99211-99215. Here is a previous response I posted regarding billing consultation CPT codes:

The following long description from Encoder Pro clearly indicates what the definition of a consultation code is as well as what is required to bill one of these codes.

Office or other outpatient consultation service codes describe encounters where another qualified clinician's advice or opinion regarding diagnosis and treatment is rendered at the request of the primary treating provider. Consultations may also be requested by another appropriate source (e.g., a third-party payer may request a second opinion). The request for a consultation must be documented in the medical record, as well as a written report of the consultation findings. During the course of a consultation, diagnostic or therapeutic services may be initiated at the same encounter or at a follow-up visit.​

The important things to remember with consults are the 3 Rs:

• Request from the treating provider (or a 3rd party such as an insurance company)
• Reason the requesting provider must state a specific reason for the consult
• Report from the consulting provider needs to be written with the consultant's opinion and the report needs to be sent back to the requesting provider.

Another tip to remember is that if the patient and/or family requested the consult you cannot bill with a consult CPT code 99242-245.

Here is a help, if a bit old, AAPC blog post link regarding billing for consults Remember the 3 Rs for Payers Accepting Consults.

I hope this helps clear things up for you and your providers.

My questions to you to determine whether or not visit this patient had with your provider qualifies as a consultation are:

• Did the patient's treating provider actually ask for the advice or opinion regarding the removal of the implant and document in the patient's medical record that they requested a consultation from your provider? Or did the treating provider refer the patient to your provider to assume care for removal of the implant? If there is no documentation that there was a request for consultation in the medical record, then this is not a consultation.
• If the documentation does indicate the request was for a consultation, did your provider write the required report which includes their opinion and send the written report back to the requesting physician? If there is no written report then it is not a consultation, although if your provider writes the report based on the requirement for billing the consultation CPT codes, it needs to be sent to the patient's treating provider per the guidelines. If there is a written report from your provider and it is sent to the patient's treating provider and criteria listed in the prior bullet point are met for a consultation, then I would say that this visit would be considered a consultation because the 3 Rs are met. The 2nd R, the reason, was listed in your post so that is why I didn't address it as a requirement for visit to be considered a consultation.

If the 3 Rs listed the post I quoted are not met then you do not have a billable consultation CPT code 99242-99245, you would have a regular office/outpatient E&M visit and would bill from either the new patient code set 99202-99205 or 9921-99215 for an established patient. I'm guessing your provider has not seen this patient before, but I know some people who have a general surgeon they have used for a variety of procedures, so I'm not assuming this is a new or established patient.

I know this is a ton of information, but consultations are tricky and are often billed inappropriately based on the guidelines and requirements for a consultation and I wanted to make sure you had all the critical information to make the correct CPT E&M code choice.

 

[theisel@lakeviewclinic.com]

It doesn't sound like this is a true consultation billed with CPT codes 99242-99245, it sounds like the patient was referred to the general surgeon to assume care for the removal of the Nexplanon because the referring provider was unsuccessful in their attempts to remove the implant. Many commercial insurance companies followed Medicare and stopped covering the consultation E&M CPT codes 99242-99245 (outpatient) and 99252-99255 (inpatient) and will only reimburse for office/outpatient E&M codes 99202-99205 & 99211-99215. Here is a previous response I posted regarding billing consultation CPT codes:


My questions to you to determine whether or not visit this patient had with your provider qualifies as a consultation are:

• Did the patient's treating provider actually ask for the advice or opinion regarding the removal of the implant and document in the patient's medical record that they requested a consultation from your provider? Or did the treating provider refer the patient to your provider to assume care for removal of the implant? If there is no documentation that there was a request for consultation in the medical record, then this is not a consultation.
• If the documentation does indicate the request was for a consultation, did your provider write the required report which includes their opinion and send the written report back to the requesting physician? If there is no written report then it is not a consultation, although if your provider writes the report based on the requirement for billing the consultation CPT codes, it needs to be sent to the patient's treating provider per the guidelines. If there is a written report from your provider and it is sent to the patient's treating provider and criteria listed in the prior bullet point are met for a consultation, then I would say that this visit would be considered a consultation because the 3 Rs are met. The 2nd R, the reason, was listed in your post so that is why I didn't address it as a requirement for visit to be considered a consultation.

If the 3 Rs listed the post I quoted are not met then you do not have a billable consultation CPT code 99242-99245, you would have a regular office/outpatient E&M visit and would bill from either the new patient code set 99202-99205 or 9921-99215 for an established patient. I'm guessing your provider has not seen this patient before, but I know some people who have a general surgeon they have used for a variety of procedures, so I'm not assuming this is a new or established patient.

I know this is a ton of information, but consultations are tricky and are often billed inappropriately based on the guidelines and requirements for a consultation and I wanted to make sure you had all the critical information to make the correct CPT E&M code choice.

Thank you for your feedback. My question was not worded well. We did not bill a consult code, but a 99203. My question is if the Z30.46 diagnosis is appropriate. I appreciate your Consult feedback, and I apologize for wording my question inappropriately.

 

[nielynco]

Our general surgeon saw a consult for the removal of Nexplanon, significant attempts were made for removal before the patient was referred to us. Is it appropriate to use the Z30.46 (encounter for surveillance of implantable subdermal contraceptive) as the primary diagnosis?

The patient is going to need surgery in the hospital to remove the device.

Corrine's reply is correct with regard to billing a consultation, but I also believe you are asking about what ICD10 diagnosis code to use for the visit (the surgery will be done at a different episode of care I take it). Since we already now there is an issue with implant I would use the applicable T code T85.618__ To T85.613__ or T85.698, or T85.898. Your provider is not doing surveillance.

 

[CBLENNIE]

Thank you for your feedback. My question was not worded well. We did not bill a consult code, but a 99203. My question is if the Z30.46 diagnosis is appropriate. I appreciate your Consult feedback, and I apologize for wording my question inappropriately.

No apologies needed. I get that in the real world the term consultation is used often and so we just use it out of habit but in the coding world it has a very specific meaning, and it is easy to use the term consultation when what you really mean is some other type of E&M or service.

I hope you have a bright and joyous holiday season.

 

[natashalage]

It doesn't sound like this is a true consultation billed with CPT codes 99242-99245, it sounds like the patient was referred to the general surgeon to assume care for the removal of the Nexplanon because the referring provider was unsuccessful in their attempts to remove the implant. Many commercial insurance companies followed Medicare and stopped covering the consultation E&M CPT codes 99242-99245 (outpatient) and 99252-99255 (inpatient) and will only reimburse for office/outpatient E&M codes 99202-99205 & 99211-99215. Here is a previous response I posted regarding billing consultation CPT codes:


My questions to you to determine whether or not visit this patient had with your provider qualifies as a consultation are:

• Did the patient's treating provider actually ask for the advice or opinion regarding the removal of the implant and document in the patient's medical record that they requested a consultation from your provider? Or did the treating provider refer the patient to your provider to assume care for removal of the implant? If there is no documentation that there was a request for consultation in the medical record, then this is not a consultation.
• If the documentation does indicate the request was for a consultation, did your provider write the required report which includes their opinion and send the written report back to the requesting physician? If there is no written report then it is not a consultation, although if your provider writes the report based on the requirement for billing the consultation CPT codes, it needs to be sent to the patient's treating provider per the guidelines. If there is a written report from your provider and it is sent to the patient's treating provider and criteria listed in the prior bullet point are met for a consultation, then I would say that this visit would be considered a consultation because the 3 Rs are met. The 2nd R, the reason, was listed in your post so that is why I didn't address it as a requirement for visit to be considered a consultation.

If the 3 Rs listed the post I quoted are not met then you do not have a billable consultation CPT code 99242-99245, you would have a regular office/outpatient E&M visit and would bill from either the new patient code set 99202-99205 or 9921-99215 for an established patient. I'm guessing your provider has not seen this patient before, but I know some people who have a general surgeon they have used for a variety of procedures, so I'm not assuming this is a new or established patient.

I know this is a ton of information, but consultations are tricky and are often billed inappropriately based on the guidelines and requirements for a consultation and I wanted to make sure you had all the critical information to make the correct CPT E&M code choice.

Thank you, Corinne, for the detailed explanation on Consult rules! I have a question please. What do you think (and other coders) about this statement that I was told. If providers are using the same electronic system like Epic, the consult MD does not need to write a Report back because the Requested MD can access the pt’s chart to see the Recommendations.

 

[CBLENNIE]

Thank you, Corinne, for the detailed explanation on Consult rules! I have a question please. What do you think (and other coders) about this statement that I was told. If providers are using the same electronic system like Epic, the consult MD does not need to write a Report back because the Requested MD can access the pt’s chart to see the Recommendations.

I would say a report still needs to be written and somehow the requesting physician needs to be notified the report is available in Epic for review. I work for a commercial insurance company, so I don't know a thing about Epic other than the health system I use for my personal healthcare uses it. I'm hoping there is a way to send a notification through Epic from the consultant to the requesting physician that the report is available. If there isn't a way to notify the requesting physician of the report's availability in Epic, then I would think some other type of communication would need to be used such as email or phone call to the requesting physician's office notifying the provider of the report being available in Epic.

The AAPC blog post states the following regarding the report requirement for consultations:

​

Lastly, and perhaps most importantly, the consulting provider must render his or her opinion and return a written report of his findings and treatment suggestions to the requesting provider. The entire reason for the service, after all, is so the consulting physician can give his opinion and advice to the requesting provider. Without a report back to the requesting provider, a consultation hasn’t occurred.​

So, while the requesting provider may be able to view the recommendations in Epic, if the provider is never notified of the information being available for their review, I don't think the requirement to report back the requesting physician is met since they don't know the consulting physician has made their recommendations and are available for review. As long as the requesting physician is made aware of the information from the consulting physician is available for review in Epic then I think the report requirement is met. I know this seems like I'm nitpicking, but I know providers are juggling numerous tasks and trying to treat patients and they aren't necessarily going to know the consulting physician made their recommendation if the requesting physician is never notified that the information is available in Epic. The requesting provider may not even know if the patient did or did not see the consulting physician, so they may not be actively checking the patient's medical record looking for the consulting physicians recommendations/report.

 

[csperoni]

I definitely agree with @CBLENNIE that if the original referring provider receives no type of notification, then it is not a consult. While I don't use EPIC currently, any EHR I've used will allow a physician to physician message, with or without the note attached. It does not need to be an actual piece of paper mailed or faxed. But the original provider needs to be informed of the findings. You can probably even have a template set for this. So something like:
Dr. Referring,
Please see my office note dated 12/27/2023 for our mutual patient regarding treatment options and plan. As always, thank you for your referral and please reach out if you have any questions or input.
Dr. Consult