Ophthalmology and Optometry Coding Alert

The answer to a reader's question in the October Ophthalmology Coding Alert ("Learn the 3 R's for Successful Consultation Billing") may have confused readers as to what is required to bill a consultation. Here is the relevant passage from the Medicare Carriers Manual, section 15506:

Pay for a consultation when all of the criteria for the use of a consultation code are met:

1. Specifically, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.

Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla., breaks down the "3 R's" for consultations as follows:

1. Request for consultation is recorded in the medical record with the name of the requesting physician or appropriate provider and the reason for the request.

2. The consulting physician renders an appropriate level of consultation, documenting all areas of history, examination, and medical decision-making.

3. Following the patient encounter, the consulting physician prepares a written report and replies to the requesting physician.

An example from Medicare's consultation policy deals with ophthalmology:

A general ophthalmologist diagnoses a patient with a retinal detachment. He sends the patient to a retinal subspecialist to evaluate the patient because the general ophthalmologist does not treat this specific problem. The retinal subspecialist evaluates the patient and subsequently schedules surgery. He sends a report to the referring physician explaining his findings and the treatment option selected.