Orthopedic Coding Alert

Question: I work for an orthopedist who does not use any new patient CPT codes. Because all of his patients are referred to him, he says that none are actually "new." He writes a report back to the primary-care physician, so he uses only the consult codes. However, he usually takes over the patient's care and makes several follow-up appointments. Is this correct coding?

Florida Subscriber

Answer: Unless your orthopedist limits his practice to one of the niche subspecialties (such as orthopedic oncology), all of his new patient encounters likely do not qualify as consultations. Not every referral should be construed as a consultation, even if the orthopedist sends a report back to the patient's primary-care physician (PCP). For instance, a PCP may evaluate a patient for knee pain and recommend that he see an orthopedic surgeon. The patient then contacts the orthopedist of his choice. Even if the orthopedist sends a report to the PCP, this does not constitute a consultation because the patient self-referred to the orthopedist on the PCP's advice.

In this scenario, the orthopedist should report a new patient code (99201-99205). On the other hand, if the PCP called the orthopedic surgeon and asked that he evaluate the patient, you may report an office consultation code (99241-99245), if the CPT requirements for reporting these codes are met (documentation of the request for consultation, opinion of the orthopedist, and any treatment rendered in a written report to the requesting physician).

If the orthopedist saw the patient for a consultation (99241-99245) and took over the patient's care after the first visit, the first visit would be treated as a consult, and subsequent visits would be billed as established patient E/M visits (99211-99215).