Ophthalmology and Optometry Coding Alert

Question: Is it appropriate for the ophthalmologist to code a consult when a primary-care physician sends a patient with medical problems (e.g., diabetes) to us for evaluation of an eye problem? We start treatment for the problem and follow the patient, but ultimately send the patient back to the primary-care physician for continued care of the other medical problems. We include documentation of the fact that the patient was sent to us, and we send a letter to the physician with a diagnosis and treatment plan. We also say that the patient will be sent back to the primary-care physician for continued care for their other medical problems.

Louisiana Subscriber

Answer: In August 1999, Medicare published a transmittal clarifying the policy for consultations. In contrast to the previous policy, the clarification states that the consulting physician can initiate treatment at the time of the consultation. The transmittal also listed three criteria the consultation must have and gave specific examples of consultations, one of which reflects the above scenario.

Consultation criteria:
(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 patients medical record.
(3) After the consultation is provided, the consultant prepares a written report of his or her findings, which is provided to the referring physician.

Consultation example:
A family physician diagnoses a patient with diabetes mellitus. The family physician asks the ophthalmologist for a baseline evaluation to rule out diabetic retinopathy. The ophthalmologist examines the patient and sends a report to the family physician of his findings. The ophthalmologist tells the patient at the time of service to return in one year for a follow-up visit. This subsequent follow-up visit should be billed as an established patient visit in the office or other outpatient setting, as appropriate.

According to CPT 2000, a consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. The written or verbal request for a consultation must be documented in the patients medical record by the consulting physician. The consultants opinion and any services that were ordered or performed must be documented in the patients medical record and communicated by written report to the requesting physician.

Guidelines for charging for a consultation follow the three Rs: request, review and report. As stated in CPT, the request for the consultation must be documented in the patient medical record by the consulting physician. The review is the consultants history, exam and medical decision-making regarding the patient that determines the level of consultation code charged. The report is the written report of the consulting physicians findings and opinion back to the requesting physician.

Diagnostic tests and initial treatment may be provided by the consultant. Visits subsequent to the initial consultation, scheduled by the ophthalmologist's office with the patient, to continue treatment of the eye problem become established patient visits and are not consultations. Note that according to the August 1999 update, even if the consultant continues treating a specific condition after the consultation, this does not negate the initial consultative service. Be cautious when using the words referred and request. In documenting the request for a consult, the patients medical record should clearly state, Patient X is seen today at the request of Dr. X for a consultation concerning an eye problem. The written report sent by the consultant to the primary-care physician should state, Thank you for requesting me to see patient X in consultation for an eye problem. The word referred can make it appear there is a transfer of care, indicating that the ophthalmologist was taking over the care of the patient and therefore could not bill a consultation.