Internal Medicine Coding Alert

Published on Thu Sep 11, 2008 PDF

Everybody who's watched a hospital TV drama knows the term "second opinion." But when your internist performs this service in the real world, be sure not to confuse it with a consultation.

The difference: A second opinion E/M service is either requested by the patient or family, or mandated (by a third-party payer), according to Chapter 12 of the Medicare Claims Processing Manual.

"It is not requested by a physician, nonphysician practitioner (NPP) or other appropriate source that meets the criteria for a consultation," Medicare states. (For more information on coding consultations, see "Record Consult Request or Face Claim Denials" on page 73.)

A second opinion, according to Medicare, "is generally performed as a request for a second or third opinion of a previously recommended medical treatment or surgical procedure." Medicare does not require a written report when a patient or family member requests a second opinion.

When the internist provides a second opinion in either the hospital or nursing facility, "then the E/M service shall be reported using the subsequent hospital care codes (99231-99233) in the inpatient hospital setting and the subsequent NF care codes (99307-99310) in the NF setting," Medicare states.

If the internist performs a second opinion E/M in an office/outpatient setting, use the appropriate E/M code (99201-99205 or 99212-99215).

Your non-Medicare insurer may want you to append modifier 32 (Mandated services) to the E/M on your mandated second opinion claims.

(A mandated second opinion might occur if an insurer requests an examination from your internist to determine medical necessity for a procedure or service.) Medicare does not recognize modifier 32 as a payment modifier, and carriers will not cover mandated second opinions. You might want to check your commercial payer contracts, however, to see it they require modifier 32 on mandated second opinions.