Otolaryngology Coding Alert

Tip: Be sure it’s clear you see the patient as a ‘loan.’

Medicare stopped accepting claims for consultations several years ago, but some private payers still reimburse for the service. If it’s been a while since you reported a consult, remind yourself of some important facts based on a scenario from an Otolaryngology Coding Alert subscriber.

Situation: I want to make sure I have this correct. The definitions for CPT^® consultation codes 99241-99245 state that they are for new or established patients. So if a primary care physician refers a patient to see the otolaryngologist for dysphagia and we have seen the patient within the past three years for otitis media, we can still report one of the consultation codes, correct? We would only submit one of these codes if our physician does not make the decision to accept transfer of care until after this initial consultation. 

Response: A consultant MAY treat a patient and ultimately take over care for the condition that they have been asked to evaluate. The consultation codes in question are:

• 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 ... 
• 99242 – Office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making … 
• 99243 – Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity …
• 99244 – Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity …
• 99245 – Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...

“The key is that there have to be three key components to a consultation which I have expanded to five so that it is easier to understand,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of the coding and consulting division of J. & S. Stark Billing & Consulting, Inc., in Shrewsbury, N.J. “Picture a consult as a borrowed patient, like a  DVD from Red Box versus a new patient or established patient is something you own, like a DVD you purchased at the store. Borrowed items can be kept as long as you need them, but you eventually have to return them to the source, like you return a DVD to Red Box.  They don’t say it has to be back in a day, but you need to eventually return it. The same goes for a patient on which your doctors do a consult.”

The components for a consultation are:

• Reason for consult (i.e., dysphasia)
• Request for your doctor’s opinion
• Rendering the service in order to develop an opinion (the consult visit)
• Write a letter (or auto generate a letter) to the requesting doctor with the opinion
• Return the patient once the course of treatment is complete.

After your physician treats the patient for dysphagia, send a letter back to the requesting physician stating that you are returning the patient back to him. Outline the details of your plan of care that you stated in your original letter and tell them how it worked out, any modifications you had to make to the plan of care, and the status of the patient.

Invite the referring physician to not hesitate in sending the patient back to you again if she has any otolaryngology problems. If your physician feels that the condition he consulted for and treated needs regular monitoring, tell the referring physician when the patient should check in with your office so you can monitor how she is doing (for example, once a year). 

All of this is to show that your physician sees the patient as a “loaner” and not a transfer to your practice.  

Another note: Don’t forget the details that differentiate a new patient from an established one. In the scenario above, the physician group had seen the patient within the last three years for a different problem. The three-year mark is the first checkpoint for determining “new” versus “established.”

“You can only code ‘new’ again if your physician is part of a different specialty or subspecialty with a different tax ID,” says Catherine Tinkey, administrator for ENT Medical Services, PC, in Iowa City. “A new complaint has nothing to do with it. In our specialty you could see a patient for an ear issue and a month later they go to the ER or see a PCP who requests a consult on a throat issue. The patient is still established with your group because the visits are within that three-year threshold and are related to the same specialty.” 

This rule applies to new versus established patients, but consultations are the same whether the patent is new or established. All you need is a request and a reason for the consultation and then “borrow” away.