Optometry Coding & Billing Alert

Question: A patient originally came to our office based on a referral for a procedure. The optometrist subsequently sees the patient for a problem that the procedure manifested. May I report a consult for the subsequent visit?

Maryland Subscriber

Answer: You should code this service as an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient -). Because the subsequent visit is for managing the patient's condition, you should not consider it a consult.
 
Exception: If the referring physician requests the subsequent consult visit, the encounter may qualify as a consultation (99241-99255). The patient's medical record should contain documentation of the request for opinion, the reason for the consultation, the rendering of findings, and a report to the requesting physician.