Consult Coding 101

Real-life coding examples distinguish between a consult and a transfer of care

Billing for a consult rather than a basic new patient visit can recoup higher reimbursement. But not so fast. Be sure you know when you can - and can't - bill a consult by learning from the examples below.
 
Consult: A primary-care physician sees a female patient for an annual preventive exam. During the exam, the patient explains that she's been having extreme menopausal symptoms. Because the patient also has a very small stature, which puts her at greater risk for osteoporosis, the physician decides that she may be a good candidate for hormone replacement therapy. He therefore sends the patient to an endocrinologist to evaluate her hormone levels and bone mass and determine if HRT would be appropriate. The physician writes a request for the opinion, and his nurse sends this to the endocrinologist.
 
When the patient presents at the endocrinologist's office, the endocrinologist does an expanded problem- focused history and exam and orders some blood tests and a bone density study. Then, at a follow-up visit to discuss all test results, the endocrinologist decides the patient should begin HRT. The endocrinologist has thereby rendered the requested opinion. After the exam, the endocrinologist sends a written report back to the requesting physician to explain his findings.
 
You code: As a coder for the endocrinologist, you review the medical chart and find a copy of the written
request, obvious documentation that the physician rendered the opinion, and a copy of the report of findings. The Three R's are fulfilled, and you therefore report 99242 (Office consultation for a new or established patient) for the first visit and 99213 (Office or other outpatient visit for the evaluation and management of an established patient) for the follow-up visit.
 
Transfer of care: A primary-care physician diagnoses a patient with adult-onset, Type II diabetes (250.00, Diabetes mellitus without mention of complication; type II, not stated as uncontrolled). The physician decides it would be best for the patient to see an endocrinologist to arrange for her diabetes care and maintenance. When the patient presents at the endocrinologist's office for the first time, the endocrinologist does an extensive exam and history and also spends 30 minutes discussing the patient's concerns, lifestyle changes the patient will need to make, and the overall plan of care.
 
You code: As a coder for the endocrinologist, you report 99204 (Office or other outpatient visit for the evaluation and management of a new patient). You may see in the medical record that the primary-care physician and the endocrinologist have been in correspondence over the patient's condition and care. However, this visit is a transfer of care and not a consultation as long [...]

- Published on 2004-04-16