Orthopedic Coding Alert

Question: Our orthopedists may refer to one another based on a provider's subspecialty, such as orthopedic oncology, etc. When my orthopedist refers to another physician within our group, should I code for an established patient, new patient, or a consult?

Nebraska Subscriber

Answer: Consultations within a group are allowed if they meet the criteria for a consultation (such as 99241-99245, Office consultation for a new or established patient ...). Medicare's Claims Processing Manual states, "Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional's knowledge."

Note: You-ll find that consultations reimburse better than E/M services, so you should make use of these codes -- as long as the visit meets the consultation criteria.

If the E/M service does not meet the criteria for a consultation -- that is, your orthopedist asks the partner to take over care -- then you would report the visit with the established patient visit codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). Most likely the patient has seen the previous physician within a time span of three years, so the new patient visit codes (99201-99205, Office or other outpatient visit for the evaluation and management of an established patient -) would not apply.