Otolaryngology Coding Alert
Consult Depends on Service,Not Diagnosis
Question: A family practitioner referred a patient with a diagnosis code to our otolaryngologist. Our office billed the visit as a consultation with that diagnosis. If the patient is referred back with a different diagnosis, can the new service still be billed as a consultation with the new diagnosis? Pennsylvania Subscriber Answer: Billing a service as a consultation (99241-99245, Office consultation for a new or established patient) depends more on whether the service meets CPT's definition of a consult rather than whether a patient is referred with a different diagnosis. If the physician who referred the patient requests an opinion regarding the new diagnosis and does not transfer the patient for care, and all other requirements for a consult are met, you should report a consultation. It may help you to think of consults as a "circle" of care, in which: 2. The otolaryngologist may provide an opinion on the patient's condition, and a treatment plan. 4. The specialist also sends a written report of his or her findings and the treatment rendered back to the requesting physician. If the otolaryngologist takes over the patient's care, however, the circle is broken. Your doctor may provide this circle of care multiple times to the same patient with the same diagnosis (request for change of treatment/plan) or a different diagnosis (new request for opinion) and may bill 99241-99245, as long as the visit qualifies as a consult. No time parameter exists between these visits. So, provided the visit meets the criteria of a consultation, you may bill one, regardless of how long has transpired since the patient's last visit. To qualify as a consultation, the visit must contain three elements:
1. The requesting physician (often a primary-care physician [PCP]) sends the patient to a specialist (the ENT) for his or her opinion.
3. At the conclusion of the opinion, the specialist sends the patient back to the PCP.
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