Internal Medicine Coding Alert

Question: A family physician requested that my internist provide a consultation on a patient for her uncontrolled diabetes. My internist documented this as a "request for consultation," but the requesting physician wrote in his chart that he was "referring" the patient to my internist. Can I still code this as a consultation?


New Hampshire Subscriber

Answer: Correctly coding this visit depends on the encounter's intent. Don't get caught up in the semantics.

If the visit's intent was for the family physician to send the patient to the internist to evaluate and manage her diabetes, then the internist should code the visit as a new or established patient visit (99201-99215), depending on whether the patient has seen the internist in the past three years.

If the family physician wanted the internist to evaluate the patient and provide a written report outlining the internist's opinion and advice for treatment, and the family physician will continue to treat the patient's diabetes, then you should code the visit as a consultation (99241-99245).