General Surgery Coding Alert

'Second opinions' become just another E/M service

You-ll have fewer choices to make when reporting consult codes in the new year: CPT 2006 will eliminate follow-up inpatient (99261-99263) and confirmatory (99271-99275) consultations.

Consequently, you-ll report all inpatient follow-up visits as subsequent hospital care.

All Follow-ups Become Subsequent Care

Beginning Jan. 1, 2006, you should report all facility visits, except the first, during the same inpatient stay using subsequent care codes 99231-99233 (hospital) or 99311-99313 (nursing facility).

Under current guidelines, the surgeon may report a follow-up inpatient consultation for subsequent visits during a single inpatient stay, as long as the visit meets the criteria of request with reason, opinion rendered, and report, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. The elimination of 99261-99263 for 2006 means that come January, you-ll no longer have that option--even if the service meets the requirements of a consult and the surgeon does not assume responsibility for any portion of the patient's care.

Don't Overlook Initial Consult

You should still report an initial inpatient consult (99251-99255) for the surgeon's first visit with the patient per inpatient stay, as long as the service meets all the requirements of a consult, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Example: The managing physician requests that your surgeon provide a consultation for a hospital inpatient complaining of rectal bleeding (569.3, Hemorrhage of rectum and anus). The surgeon documents the request, examines the patient and shares his findings with the managing physician.

In this case, you should report an initial inpatient consult (for example, 99254, Initial inpatient consultation for a new or established patient ...), as well as any diagnostic tests the surgeon provides (for example, 45330,Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).
 
Don't forget: You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code in this case because the surgeon provided a same-day procedure.

The next day (let's say Jan. 3, 2006), the managing physician once again asks the surgeon to examine the patient because of new symptoms. Again, the surgeon documents the managing physician's request, examines the patient and shares his findings. 

For the follow-up visit, claim subsequent hospital care (for instance, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). This visit looks like a consult, but you must report subsequent care because 99261-99263 will not be valid for 2006.

Celebrate the Change

Some good news: Deletion of 99261-99263 will ease documentation requirements for physicians and headaches for coders trying to choose between follow-up consults and subsequent hospital care, Hvizdash says. You can simply choose 99231-99233 for hospital inpatients or 99311-99313 for nursing facility patients.

And some great news: As a bonus, subsequent hospital care codes generally reimburse better than have follow-up inpatient consultations. -Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,- Callaway says.

Forget About 99271-99275

CPT 2006 will also eliminate codes 99271-99275 (Confirmatory consultation for a new or established patient ...). Therefore, you-ll have to report either a standard outpatient E/M service (99201-99215) or a consultation (99241-99245)--depending on the circumstances--for so-called -second (or third) opinions.-

-With no confirmatory consults in 2006, you-d treat these services like any other E/M service,- Hvizdash says. -If the surgeon receives a request from another physician to examine the patient, renders an opinion and provides a response, you have an outpatient consult. If the visit doesn't meet the requirements [such as when a patient -self-refers-], you-d charge for a standard office visit.-

Example: A patient recently diagnosed with intestinal cancer (for instance, 153.x, Malignant neoplasm of colon) seeks a second opinion before undergoing surgery to remove the affected tissue. Your surgeon provides a full workup and discusses possible outcomes with the patient.

In this case, you should report an appropriate-level new patient visit (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...).

Ask for an ABN for Second Opinions

You should obtain an advance beneficiary notice (ABN) from a patient prior to rendering the service if you know that the patient is seeking a second opinion or confirmation of a diagnosis or treatment plan. The ABN lets the patient know that he may be responsible for payment if the insurer deems the service unnecessary.

Why it's worth the effort: In the past, many payers (including Medicare) have not covered confirmatory consultations because the insurers considered such second opinions (especially when generated by the patient or patient's family) a -duplication of services.-

This problem may continue to haunt physicians who provide second opinions for patients: Because another physician has already examined the patient and provided an opinion, the payer may deem any attempt to re-examine the patient a duplication of services--even if you bill the care as an office visit or inpatient or outpatient consultation.