Ophthalmology and Optometry Coding Alert

Question: Several hospital physicians are referring patients to my physician for "consult. When I code those visits, I am not sure if I should code for a new patient office visit or an office consultation. How do I tell the difference?


Oregon Subscriber

Answer: To be able to report a consultation code (99241-99255), there are a few requirements that your physician's visit with the patient must meet. Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:

• Request for opinion

• Rendering of services with recommendations

• Report or response to the requesting source.

Last December, CMS added reason to the consultation R's. Transmittal 788 requires that the requesting physician document the request and the reason for a consult in the patient's medical record.

Important: These are Medicare guidelines only, but private payers generally accept them.

Key point: When the physician provides a consultation at the request for an opinion and/or advice for a specific reason, examines the patient and provides recommendations for treatment, he must also provide a separate report to the requesting physician.

In a setting where the medical record is shared, it is not necessary to provide a separate report, but the consulting physician's findings and recommendations must be available for review. The consulting physician may start treatment. In this case, the criteria for a consultation have been met.

If, however, your physician's opinion/advice is not being requested, and the patient is sent to you to provide care and management of an ophthalmic problem, the criteria for consultation have not been met.

In other words, ask yourself: Is the initial physician requesting your feedback (opinion, advice, recommendations for treatment)? If so, it's a consult. Or, is the initial physician sending you a patient to care for because it is a problem that is outside his area of expertise (or an emergency department physician asking a patient to follow up with an ophthalmologist following treatment in the emergency department)? If the initial physician does not request your opinion, nor is he expecting a response of your findings, it is not a consultation.

Alternative: If you don't meet the consult requirements, and the patient has not seen a physician in your practice within the past three years, you should instead select an appropriate-level new patient E/M visit (99201-99205).