Ophthalmology and Optometry Coding Alert

Question: We commonly see patients referred by another physician. Our ophthalmologist performs an office exam that frequently results in a later procedure. Should we code these as consultations or transfer of care? Do we need a written notice from the referring physician for consultations?

Texas Subscriber

Answer: Consultations are requests from an appropriate provider for advice, opinion, or recommendations on treatment. This can be for a known or unknown problem. Therefore, if a provider is sending patients to your ophthalmologist for the same problem on a regular basis, the request can be interpreted as a transfer of care for your physician to manage the problem. This is not a consult and should be billed with the 99201-99215 (new or established) office visit code (99201-99215, Office or other outpatient visit ...) as appropriate.

On the other hand, if an appropriate provider sends the patient to your ophthalmologist with the intent of receiving a recommendation on how to treat the patient's condition after the consulting physician evaluates the patient, then this would be a bona fide consultation (CPT® codes 99241-99245, Office consultation for a new or established patient ...). The requesting provider's intent is to handle the care of the patient's condition based on the consulting physician's recommendations. It is okay for the consulting physician to begin treatment, however. The requesting physician can then take over and continue the treatment as recommended.

Consultation requests that occur over and over from one provider to another when the intent of the requesting physician is for the consulting physician to evaluate, manage, and treat that condition are not consultations. This is clearly demonstrated when the requesting physician continues to send patients with the same or similar problems to another provider. At some point, it becomes very clear that the requesting physician is not asking for recommendations but is, in fact, asking your physician to evaluate and treat the patient.

For those rare situations when a true consultation request does occur, there should be documentation in the requesting physician's medical record to support the request. Further, the consulting physician should document:

• Name of the requesting provider
• Reason for the consultation
• Review of any medical records sent with the patient
• An appropriate history and examination and impression as rendered by the consulting physician
• Recommendations for treatment
• A written report of the encounter provided to the requesting provider.

Finally, if the consulting physician has started treatment, a statement of "I have taken the liberty to begin treatment" is appropriate in the medical report to the requesting provider. Again, the intent is to make recommendations to the requesting physician so that the requesting physician can receive the patient back and manage the patient's treatment.

Any patient who is referred to your ophthalmologist for evaluation and treatment is not a consultation and should not be coded as such. The intent is clear, and that is for another physician to provide management of the patient's problem.