Medicare Compliance & Reimbursement

Make haste — Jan. 1 is right around the bend.

If you’re in preparation mode for next year, now is a good time to review the CPT® 2023 basics. To help you start the year off right, we’ve put together some practice scenarios to help you put your consultation coding to the test.

Keep reading for expert advice on how to choose the level of medical decision making (MDM), what to do when a provider performs diagnostic testing during the consultation, and if payers will even reimburse for consultations.

Find Out What Factors Into MDM Level

When a patient visits your practice for a consultation, several factors will influence the service level and your code selection. 

The patient may be experiencing multiple new or established conditions at the time of the encounter, which alone would not determine the level of MDM. However, whether the conditions are acute or chronic is likely a key factor. “The 2023 modifications to the 2021 evaluation and management [E/M] guidelines MDM do not change the 2021 guidance that the ‘new or established’ conditions do not matter as much as whether those problems were addressed and managed,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Keep in mind: Choosing the appropriate level of MDM requires more than determining the number and complexity of problems addressed at the encounter. “With the revised MDM calculations, the coder must also consider the amount or complexity of data to be reviewed and analyzed, as well as the risk of complications or morbidity or mortality of patient management. Two of these three areas must meet or exceed the requirements for any given level in order to assign an E/M code,” adds Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager at EisnerAmper Advisory Group in Iselin, New Jersey.

Consider this specialty scenario: An allergist sends a patient with pain, tenderness, and swelling around their cheeks and nose to a specialist for a consult. The otolaryngologist determines the patient has an acute exacerbation of their chronic rhinosinusitis and needs prescription management, as they have experienced several rhinosinusitis exacerbations throughout the year. After the two physicians discuss patient management, the allergist decides to follow the ENT’s recommendations regarding drug therapy.

“This case could qualify as moderate complexity for the problem management; since one chronic illness with exacerbation was addressed, data falls into the moderate level, as there was discussion of management with an external physician and prescription management, which places the risk in the moderate level,” Cobuzzi explains.

The provider met moderate complexity in all three areas, even though two areas would have sufficed, which means that the appropriate consultation code is 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded).

Do This When a Consultation Leads to Dx Testing

During an outpatient consultation, the provider may decide to perform a diagnostic test to receive up-to-date results before finalizing a treatment plan. Take the following steps to determine if you can report the consultation and diagnostic testing codes together:

• Step 1 – Prove medical necessity: Review the provider’s documentation to ensure the diagnostic test and the E/M visit are both medically necessary and documented.
• Step 2 – Check National Correct Coding Initiative (NCCI) and payer edits: Look through NCCI and payer-specific edit pairs to confirm whether your selected CPT^® codes are bundled and shouldn’t be separately reported for the same encounter.

Scenario: A primary care provider (PCP) requests that an otolaryngologist consult on a new patient and advise how to best manage and treat their chronic otitis media. The otolaryngologist documents that since the patient has only been evaluated by their PCP, it’s necessary to perform bilateral tympanometry to evaluate middle ear function and to establish a baseline for the condition before making any suggestions. After examining and testing the patient, the ENT recommends a course of antibiotic drops, and if the patient continues to have repeated infections, possibly tympanostomy tubes in the future.

For this visit, you’ll need to report the correct consultation code along with the CPT^® code for the impedance testing. Since this case involves a chronic problem with exacerbation, which is moderate problem management, and the doctor is prescribing antibiotic drops, which is moderate risk, you should assign code 99244. Then you’ll use 92567 (Tympanometry (impedance testing)) to report the tympanometry testing.

In this scenario, the otolaryngologist documented the need for tympanometry testing during the consultation. Additionally, 92567 isn’t bundled with 99244 in the NCCI edit pairs (based on fourth-quarter 2022 edits), which means you can report both codes for the encounter.

Change Up Your Coding for Certain Payers

Many providers misunderstand the CPT^® concept of consultations, and the codes are often used inappropriately, such as when a physician or other provider refers a patient to a specialist. “Per CPT^®, the key requirement of a consultation is that a physician or other appropriate source requests an opinion or advice from a physician; and that physician renders the advice and/or opinion back to the requesting provider,” Clark says. CPT^® revised the 2023 E/M consultation guidelines to eliminate the “transfer of care” term since the term may have caused confusion as to the appropriate use.

At the end of the day, the real question is if payers will even reimburse for consultations. “Medicare does not recognize consult codes, and will likely still not recognize them,” Cobuzzi notes. This is due to, in part, the misuse and under-documentation of consultation codes.

If a payer doesn’t recognize consultation codes and a practice submits one, the practice will likely receive a denial indicating the procedure code is not covered. “In this case, the practice has the opportunity to identify the issue, correct the claim, and resubmit the appropriate new or established patient code,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. For payers that do not accept consultation codes, the appropriate level of new or established patient E/M service should be utilized, Cobuzzi explains.

You’ll report a new (99202-99205) or established (99212- 99215) patient E/M visit code instead of outpatient consultation codes, depending on if the patient has received face-to-face services from a provider in the practice within the last three years. Note that the established E/M visit code range does not include 99211 and instead starts with 99212. This is because consultation codes start with 99242, with low MDM, and because 99211 is not a physician service and does not have MDM associated with it.