Otolaryngology Coding Alert

Question: When another doctor refers a patient to our surgeon, who meets with the patient in the office before going on to perform surgery at a later date, is this a new patient visit or a insultation?

Our surgeon always sends a report to the referring physician. Sometimes the other doctor sends a written referral, but sometimes we just get a phone call or the patient states that her doctor referred her -- does that impact the coding?

Arizona Subscriber

Answer: You can bill the situation you've described as a consultation (99241-99245, Office consultation for a new or established patient ...) under the 2010 consultation guidelines.

A consultation is a request for opinion, advice, or guidance, and your surgeon is always providing that service when he must examine a patient prior to deciding whether to become involved in the patient's care.

That's not all: Make sure you meet all of these requirements before you bill a consult code:

Another physician or appropriate source must refer the patient. You must document the referring physician's name in the consultant's note;

• You must document the reason for the patient referral in the consultant's note;
• You must document the history, exam, and decision making;
• Your surgeon must provide a written reply to the requesting provider.

If you don't meet any of these steps, such as a patient who is self-referred or referred by a friend, you should use the newpatient codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient...). All of this information is available in the CPT guidelines to the consultation codes.

Rules changed Jan. 1: You used to need a written referral to bill a consultation, but starting in 2010, you no longer needed a written request from the referring provider. Prior to 2010, Medicare was adamant about the written request requirement. Because Medicare no longer recognizes consultation codes, CPT's rules are definitive for billing consultations.