Pain Management Coding Alert

Question: A new patient came to our practice to discuss whether she should start therapy for carpal tunnel syndrome (CTS). She said that she thought she might need the therapy because she was worried about her job as a secretary causing future problems, which she had told her primary physician about. The PCP did not refer her to our practice, however. She found us on her own and decided she needed to see a pain management physician. Should we bill the visit as a consultation?

Idaho Subscriber

Answer: No, you should not consider the encounter a consultation because the primary care physician (PCP) did not ask your provider for an opinion, and your provider is not obligated to send results to the other provider.

By definition, according to CPT®, a consult is “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

That means you would need a verbal or written request for an opinion from the patient’s PCP before you could bill for a consultation. Depending on the payer, you don’t necessarily need a letter from the other provider, but there should at least be a note in the record that states “Patient is sent by Dr. XYZ for a consultation at the request of Dr. D for evaluation of ABC condition.”

After the visit, a consultation would entail a written report back to the requesting physician explaining the opinion that was requested.

For these reasons, you should not code this as a consultation, but rather, use a new patient code from among 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …).