Orthopedic Coding Alert

Question: Our surgeon examined a patient in the office and sent a report about the patient’s condition to a provider who requested it. Should we bill an office evaluation and management (E/M) or a consult (99451 or 99452); or both?

Montana Subscriber

Answer: If your surgeon provides information about the patient to another provider who requested a consult from your provider, you should report only a consult E/M code (unless the payer is Medicare), not an office E/M code.

If the surgeon documents a consult, you should not bill 99452 (Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes). As its descriptor indicates, 99452 describes a service provided by the requesting physician or other qualified healthcare professional — the other provider in your situation.

You also would not use 99451 (Interprofessional telephone/ Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time). CPT^® guidelines preceding codes 99451 and 99452 state that providers must conduct these interprofessional telephone/Internet/electronic health record (EHR) consultations “without patient face-to-face contact with the consultant,” but you imply that the service involved face-to-face contact.

Per CPT^®, assuming the necessary conditions were met (such as a documented request by the other provider and a written report prepared for that provider), you would report the appropriate consultation code reflecting the level of service provided. For outpatient consultations, you would report from among codes 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. …) through 99245 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. …).

Caveat: However, some payers, such as Medicare, no longer recognize CPT^® consultation codes and require physicians and other qualified healthcare professionals to report a different E/M code reflecting the appropriate site of service. So, you should check with your payer to see if you may need to report an appropriate office/outpatient E/M code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set rather than a code from 99241-99245.