Otolaryngology Coding Alert

Don’t automatically dismiss 99241-99245 for every patient. 

Although CMS stopped accepting claims for office consultation services in January 2010, some private payers still reimburse for the service – and some coders still have trouble with correct reporting. Decide what you think about the following scenario from an Otolaryngology Coding Alert subscriber and then see what our experts advise. 

Situation: We have a colleague we routinely refer to who generally sees our patients initially, charges a consult, and then has them back for follow-up a year later. She is charging a consult again for that follow-up visit. Is this appropriate? 

Understand What Constitutes a Consult 

According to CPT®, a consultation is a “type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” 

Note: When requested by a physician or other appropriate source, a consultation may be provided by a physician or qualified non-physician practitioner (NPP). In order to be a qualified NPP, performing a consultation service must be within the scope of practice and licensure in the state in which the NPP practices and the NPP must bill out the consultation under their own NPI, since incident to rules require the plan of care be established by a physician, meaning that a new problem would not be cared for by a NPP as an incident to service.

A consultation requested by a patient or family would not be reported as a consultative service. An appointment the patient schedules to seek a second opinion also does not fit the CPT® definition of a consultation code. However, you can report these visits using another applicable E/M service code such as an office visit code (99201-99205 for a new patient or 99211-99215 for an established patient).

Verify Documentation of Criteria

Before you can consider a service a consultation, your provider must meet and document the following criteria:

• A request for a physician’s opinion from the requesting physician (or other appropriate source), along with the need for a consultation, must be documented by the consultant in the patient's medical record and included in the patient's medical record of the requesting practitioner. This should also include the reason for the request for the consultation.
• An opinion is rendered by the consulting practitioner. This opinion, along with any other service provided, is documented in the patient's health record. 
• A written report of the consultant's findings and opinion or recommendation is communicated back to the requesting practitioner.

If you can code the patient’s visit as a consultation, choose the appropriate code from 99241-99245 (Office consultation for a new or established patient …).

Therapeutic and diagnostic procedures may be performed by the consultant at the time of the consultation. Once that initial visit is complete, and the physician has accepted to follow the patient for the care of the reason that they were sent for their opinion, subsequent visits are considered subsequent office visits (99212-99215).  

Assess the Subscriber’s Scenario 

When deciding how to handle the subscriber’s situation, start by asking some background questions. 

“First, did your physician (or any other provider) request the physician’s opinion in the second year?” asks Gloria Sikora with Trinity Mother Frances Hospitals and Clinics in Texas. “Second, it could be assumed since she is following the patient that she accepted care of the patient (for that problem) and perhaps should not have charged a consult in the first place.  The idea of a consult is to render an opinion (it is OK to follow through with diagnostic and/or therapeutic procedures for the problem), but then return care of that patient to the PCP or other physician who may be the requesting provider of that opinion.” 

Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J., agrees. “Unless the other doctor’s opinion is asked for, each time that the follow up for annual surveillance is done, it is a follow-up visit, not a consult. If the Plan of Care is to follow up with the patient in the year and check up on them, it is a follow up visit.  

Remember: For each consult, the opinion of the consultant needs to be requested from the referring physician in order for the consult to be valid (assuming the payer is a payer who accepts and processes on consults).  

“Otherwise, there are not any consults anytime, even when the consultant’s opinion is being requested (such as with Medicare and any other payers who follow Medicare’s rules for consults),” Cobuzzi says.

If the patient is non-Medicare and the payer has not indicated that they follow Medicare’s rules for consultations, you could code from 99241-99245 for the consultant services in an outpatient setting. The level of consultation is based on the documentation in the medical record and the documented problem(s) establishes medical necessity for the consultation.

If the patient is Medicare or is covered by a payer that doesn’t recognize consultation codes, report the most appropriate E/M office code for the service.