Otolaryngology Coding Alert

Question: We have taken on a facial/plastics physician who is going to see only skin cancer patients sent over from a dermatologist's office down the hall. The facial/plastics physician will evaluate the patient and decide on a surgical method/treatment, even though we already know these patients have a skin cancer. Should we report this as a consult, or a new patient visit?

Ohio Subscriber

Answer: The answer depends on the intent of the dermatologist and the insurer. If your facial/plastics surgeon's opinion is being asked, the encounter is a consult (99241-99245, Office or Other Outpatient Consultations, New or Established Patient) for non-Medicare patients. If the patient is coming in for a full transfer of care or is a Medicare patient, the visit is a new patient visit (99201- 99205, Office or Other Outpatient Services, New Patient),or an established patient if this patient has been seen by your practice in the past three years (99212-99215, Office or Other Outpatient Services, Established Patient).

Regardless, your facial/plastics physician hopefully performed a full E/M service, got to know this patient, and documented the options for care the physician considered once she completed the history, exam, and medical decision making.

If so, include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with the E/M code, provided that the physician also performed a procedure on the same day, to indicate that she provided and documented a significant, separate E/M, in addition to evaluating the skin cancer for which the dermatologist referred the patient. Remember, if the facial/plastics physician completed only a problemfocused or expanded problem-focused exam relative to the cancer, you should select a low-level E/M code.

Lastly, don't forget that Medicare no longer accepts consult codes effective Jan. 1, 2010. If the patient is covered by Medicare, you would report an office visit code, regardless of whether there is a transfer of care.