Otolaryngology Coding Alert

Question: Shouldn't you report 99271-99275 as the answer to the November 2003 Reader Question "Count Self-Referrals as Office Visits"? CPT consultation instructions state, "A 'consultation' initiated by a patient and/or family, and not requested by a physician, is not reported using initial consultation codes but may be reported using the codes for confirmatory consultation or office visits, as appropriate."

New York Subscriber

Answer: CPT's consultation notes direct you to confirmatory consultations (99271-99275), but the instructions also refer you to office visits (99201-99205), as appropriate. The final phrase, "as appropriate," means that you may report either a confirmatory consultation or an office visit based on whether the patient- and/or family-initiated request qualifies as a confirmation consultation.
 
The problem is that the reader question's example doesn't meet a confirmatory consultation's request. You should use confirmatory consultation codes "when the consulting physician is aware of the confirmatory nature of the opinion sought (e.g., when a second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure)," according to CPT. In other words, you should use 99271-99275 when the patient wants a second opinion or when an insurer requests a specialist's opinion.
 
In "Count Self-Referrals as Office Visits," a patient who has frequent sinus headaches self-refers herself to an otolaryngologist. She doesn't request the otolaryngologist's opinion on her primary physician's treatment recommendations or diagnosis; rather, she requests the specialist's advice on her condition and treatment. Therefore, the visit is not a confirmatory consultation, but an office visit. If the patient instead requests the otolaryngologist to confirm another physician's opinion or counter an initial diagnosis, the service would qualify as a confirmatory consultation (99271-99275).
 
Remember: Most carriers, including Medicare, don't cover confirmatory consultations in which a patient or family member makes the request. In these cases, you should notify the patient of his payment obligations and provide an advance beneficiary notice to Medicare patients for whom you deliver this service.

 - Information for answers to You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; Michael J. Hammer, MA, L/CCC-SLP, associate director, in the laryngeal laboratory department of otolaryngology - head and  neck surgery at the University of Kansas School of Medicine in Kansas City; James N. Palmer, MD, assistant professor in the division of rhinology in the department of otorhinolaryngology, head and neck surgery at the University of Pennsylvania in Philadelphia; and Kim Pollock, RN, MBA, an otolaryngology consultant with Karen Zupko & Associates in California.