Orthopedic Coding Alert

Question: A back-pain patient asked our orthopedist whether he could alleviate her pain through nonsurgical means instead of vertebroplasty, which her prior orthopedic physician recommended. We reported 99271-99275 because we considered it a confirmatory consultation, but our billing company said we should have reported a standard office visit code. Who is correct?

New York Subscriber Answer: In this situation, individual payer policy will determine the correct code. CPT's consultation notes state, "A 'consultation' initiated by a patient and/or family, and not requested by a physician, is not reported using initial consultation codes but may be reported using the codes for confirmatory consultation or office visits, as appropriate." The final phrase, "as appropriate," means that you may report either a confirmatory consultation or an office visit based on whether the patient/family-initiated request qualifies as a confirmatory consultation.
 
The problem is that your example may not meet the definition of a confirmatory consultation for your insurer. You should use confirmatory consultation codes "when the consulting physician is aware of the confirmatory nature of the opinion sought (for example, when a second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure)," according to CPT.
 
In other words, you should use 99271-99275 when the patient wants a second opinion or when an insurer requests a specialist's opinion. Many managed-care payers reimburse confirmatory consultation codes only when an insurer requests the second opinion, not when the patient initiates the request for a second opinion.
 
 If a new patient refers herself to your practice but doesn't request your orthopedist's opinion on her prior physician's treatment recommendations or diagnosis, the visit may not be a confirmatory consultation, but an office visit (99201-99205). If the patient instead asks you to confirm another physician's opinion or counter an initial diagnosis, the service may qualify as a confirmatory consultation (99271-99275). Always obtain your payer's confirmatory consult reimbursement guidelines to ensure that you report these codes correctly.