Internal Medicine Coding Alert

Find out whether 99271-99275 will warrant regular E/M codes come January

Just when you thought you knew how to code an encounter in which a patient requests an internist's second opinion on a surgeon's treatment plan, the AMA throws you a curve ball:

CPT 2006 will delete confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient ...). Here is a preview of how you will have to handle coding these services when CPT 2006 takes effect.

Use Site, 3 R's to Code Confirmatory Consult

While it is certain that 99271-99275 are on the chopping block for CPT 2006, it is unclear what replacement codes or guidelines CPT 2006 has in store. A confirmatory consultation could qualify as an office visit, an outpatient consultation, or an inpatient consult, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager at Medical College of Wisconsin in Milwaukee.
 
CPT's tentative explanatory language doesn't offer a definitive answer. Depending upon the site of service, these services should "be reported with the consultation or non-consultation E/M codes that are appropriate to the setting of care and consistent with the definition of consultation," state CPT's agenda notes following 99271-99275's deletion.

Translation: To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets the three requirements for a consultation--request of opinion, rendering of services and report to the requester--you should report a consult code.

Opt for E/M if Source Doesn't Qualify

A source that meets a confirmatory consultation's criteria may not count as an "other appropriate source" for an outpatient (99241-99245, Office consultation for a new or established patient ...) or inpatient consultation (99251-99255). "When a patient requests a second opinion, we currently code the encounter as a confirmatory consult," says Nicole Tanner, coder at Advanced Healthcare in Milwaukee. But CPT does not consider a patient, family member or insurer an appropriate source for a standard consultation.

To report 99241-99245 or 99251-99255, an appropriate source--such as a physician, counselor, nurse or nurse practitioner--has to generate the request. Under current coding guidelines, a confirmatory consultation's source would fail to meet a consultation's Three R's.

Physicians could have to report an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) instead of a confirmatory consult due to lack of an appropriate requesting source, says Rhonda Buckholtz, CPC, administrator at Wolf Creek Medical Group in Grove City, Pa. "That means, anytime a life insurance company or disability insurer requests an internist's confirmatory opinion, you will have to submit a regular E/M code."

Prepare to Take a $40 Hit

Giving up some confirmatory consultations probably won't affect your bottom line, provided the patient is new. Only new patient office visit codes 99201-99202 pay less than their confirmatory consult-level counterparts, 99271 and 99272.

But if you have to code an established patient visit instead of a confirmatory consult, you'll lose dollars. For instance, having to replace 99273 with 99213 will cost you $38.27, based on the 2005 National Physician Fee Schedule Relative Value File. "That's a huge difference, even if the physician performs only a handful of confirmatory consultations per year," Buckholtz says.

Research Payer Source Policies
 
Before you submit insurer-generated confirmatory consultations as regular E/M services, check with the payer for coding guidelines, Buckholtz says. "Perhaps the company will accept an unlisted-procedure code," she says.

Remember: You can still use modifier 32 (Mandated services) on the E/M code. "If an insurer requests the opinion, you should indicate a mandated service with modifier 32," Buckholtz says. "Insurer-mandated services were the only type of confirmatory consultations that insurance companies paid."

Your consultation coding and insurer payment is less guaranteed with a patient-generated request. Here's how these cases will change coding-wise.

Illustration: After a urologist recommends an open nephrectomy, the patient asks his internist for a confirmatory opinion. Because a family member makes the request, your consultation coding is ambiguous.

Now, you should report the visit as a confirmatory consult with 99271-99275. In 2006, you should verify whether the insurer considers this a consult or an outpatient new or established patient visit.