Ophthalmology and Optometry Coding Alert

Question: What is the correct way to bill a consultation in the emergency department? An ED doctor called in one of our ophthalmologists to see a patient. I've heard in the past that these need to be coded as an ED visit and not a consult, but this doesn't seem right.

South Dakota Subscriber Answer: Whether you bill for a visit or a consultation depends on the nature of the visit and how it is documented. The confusion on how to bill when seeing the patient in the ED setting is that your doctor is "on-call" and responsible for seeing patients after hours. But that does not negate the nature of the visit and the consultation request from the ED doctor. As long as you meet the documentation requirements, you should bill the appropriate level of consultation that was rendered (99241-99245, Office consultation for a new or established patient).

Do this: When you bill a consult, section 15506 of the Medicare Carriers Manual (MCM) specifies that you must have three things (the Three R's):

1. Request: A physician or other appropriate source must make a written or verbal request for a consultation (unless it is a patient-generated confirmatory consultation). Medicare states that this requirement is fulfilled if the consulting physician documents the request for consultation in his notes, an order in the medical record, or a specific written request for the consultation.

 2. Review: A request for the consulting physician's review from an appropriate source and the need for consultation must be documented in the patient's record.

 3. Report: After the consultation is provided, the consultant prepares a written report of his findings, which is provided to the referring physician. This often includes a recommended plan of treatment or care for the patient.