Optometry Coding & Billing Alert

Question: A local gastrointestinal specialist called and wanted our optometrist to check one of his patients for the presence of a Kayser-Fleischer ring. The time involved to check the patient was minimal, and there was no need for treatment. Our optometrist sent a letter confirming his observations back to the treating physician. Does this qualify as a consult, or should we bill a confirmatory consultation code?

Texas Subscriber

Answer: You should probably bill an outpatient consultation code for the visit. For you to bill a consultation, the Three R's must be present: request, render and report. There must be a written or otherwise well-documented "request" from the patient's treating physician for a consultation. Your optometrist must "render" the consultation by performing and documenting the necessary history, exam and medical decision-making.

And your optometrist must send a "report" of his findings and final opinion to the requesting physician. If the medical chart contains documentation of these three consultation requirements, you should bill the appropriate-level outpatient consultation code (99241-99245).

A confirmatory consultation code (99271-99275) is most likely not appropriate for this situation because a confirmatory consult is usually initiated by the patient and/or a family member, not the treating physician.

The visit would qualify as a confirmatory consultation if your optometrist's notes indicate a casual request from the treating physician for a second opinion - with no formal documentation of a consultation. "A physician consultant providing a confirmatory consultation is expected to provide an opinion and/or advice only," according to CPT. Since your optometrist sent a written report of findings back to the requesting physician, you probably have enough documentation to qualify the visit as a consultation.

Watch out: Carriers don't usually cover a second opinion, or confirmatory consultation, unless the payer is the requesting entity. If a third-party payer requires the confirmatory consultation, you should append modifier -32 (Mandated services), CPT states.