Otolaryngology Coding Alert

 Heads-up: You should be able to code 4 types of consults

Knowing how to report a consultation's correct service level and understanding Medicare's documentation requirements can get your physician's consults paid and keep you compliant with the feds, coding experts say.

Spot Consultation Documentation

Before you can use consultation codes (99241-99275) with confidence, you should understand how a consult differs from a regular office visit, coding experts say.

Generally, a consultation means a physician, other healthcare practitioner, patient or other third-party has requested that your allergist render advice on a specific problem (such as diagnosing a condition), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

On the other hand, an office or inpatient visit involves ongoing care of the patient, according to CMS guidelines.

Consultation example: A surgeon requests your allergist's opinion on whether a patient with asthma (493.xx) is fit for surgery. Depending on location and documentation, you could report the appropriate consult code (99241-99275).

If, however, a physician transfers a patient's complete care to your allergist, you would have to choose the appropriate new patient E/M code (99201-99205), Pohlig says.

3 Easy Ways to Support Consultations

Because Medicare has received so many incorrectly coded consultations, you may think reporting these visits with accuracy is a daunting task. But you can code consults with ease if you remember the three R's:

Request: Another physician, provider, patient or private insurer has to request your allergist's advice or opinion. Your physician can document this request in his report back to the referring physician, Pohlig says.

Review: This means the allergist has actually evaluated the patient and formulated a plan of care, Pohlig says. For instance, if during a consult your allergist determines that a patient has unspecified allergic alveolitis and pneumonitis (495.9), he should document this diagnosis.

Report: Your allergist has to give the requesting physician a report of his opinion or advice, Pohlig says. In the report, your physician should mention the request, provide his opinion on the patient's condition, and possibly include a treatment plan.

How to Code 4 Different Consultations

CPT didn't create all consultation codes equally - so you shouldn't code your physician's consults the same way. You'll need to know how to code four different kinds of consultations:

1. Office or other outpatient consultations (99241-99245)

You should report 99241-99245 when the allergist provides a consultation in the office or other ambulatory facility, such as the patient's residence, a hospital observation unit or an emergency department.
 
Example: A pediatrician sees a child for the first time and suspects her of having both allergic rhinitis (477.x) and asthma. To confirm the diagnoses, and to receive advice on how to manage multiple allergic conditions, the pediatrician sends the child to your allergist for an evaluation. Your allergist confirms the diagnoses and recommends a treatment plan of environment control and medication injections.
 
According to the medical documentation, the physician performed an expanded problem-focused history and exam, and straightforward medical decision-making. The visit took 35 minutes, so you report 99242.

2. Initial inpatient consultations (99251-99255)

The allergist provides these in an inpatient hospital, skilled nursing facility, or partial hospital setting. You can report 99251-99255 only once per inpatient admission.

Example: A man with anaphylactic shock due to adverse food reaction (995.6x) goes to the hospital. After treating the anaphylactic shock, the patient's internist requests that your allergist render an opinion and offer advice on controlling the patient's food allergy. Your physician evaluates the patient and makes the recommendations. Based on the documentation and time spent with the patient, you report 99253.

3. Follow-up inpatient consultations (99261-99263)

Use these codes when your allergist completes an initial inpatient consultation or provides a new consultation after he's already performed an initial inpatient consultation during the single admission. Follow-up consultations include monitoring progress, recommending treatment modifications, or advising on a new care plan if the patient's status has changed.

Coding tip: You should not report 99261-99263 for any subsequent hospital visits the consulting physician provides, says Bruce Rappoport, MD, CPC, a board-certified allergist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise. If your allergist manages the patient's care following the initial inpatient consultation, you should use the appropriate subsequent hospital code 99231-99233, he adds.

Example: Using your allergist's advice, the internist attempts to control the patient's food allergy. But five days later, the patient suffers another reaction, so the internist calls your physician in for a second consultation. Because the guidelines only allow one consultation per admission, your physician now will use the follow-up consultation codes for the second visit. You report 99262, because the documentation shows an expanded problem-focused exam along with medical decision-making of moderate complexity.

4. Confirmatory (or second opinion) consultations (99271-99275)

Patients often request these to get a second opinion to another physician's diagnosis. Also, third-party insurers may request them before they approve a medical treatment or surgical procedure. You can report 99271-99275 for both inpatient and outpatient confirmatory consults.

Example: An allergist determines a young woman has asthma and recommends that she undergo allergy immunotherapy to control the condition. To confirm her physician's diagnosis and the necessity for the immunotherapy, the woman presents to your allergist for a second opinion, which he delivers.

The medical documentation shows the visits meets 99272's requirements of expanded problem-focused history and exam, and straightforward decision-making regarding a low-severity problem.