Primary Care Coding Alert

CPT's ambiguous language doesn't seal confirmatory consult void

When a patient requests a family physician's opinion on another doctor's treatment plan, new guidelines indicate that you may have to report an office visit instead of a consult code.

CPT 2006 will delete the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient -) and thereby eliminate your shoe-in codes for reporting this services in the future. Here is a preview of how you will have to handle coding these services when January rolls around.

Choose Alternatives Based on Site

CPT's intended replacements codes for 99271-99275's aren't clear-cut. A confirmatory consultation could potentially qualify as an office visit, an outpatient consultation or an inpatient consult, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager at Medical College of Wisconsin in Milwaukee.

But CPT's tentative explanatory language doesn't offer a definitive answer. Depending on the site of service, confirmatory consultation services should -be reported with the consultation or non-consultation E/M codes that are appropriate to the setting of care and consistent with the definition of consultation,- state CPT's agenda notes following 99271-99275's deletion.

Translation: To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets the three requirements for a consultation--request of opinion, rendering of services and report to the requester--you should report a consult code.

Consider Using the Standard Office Visit Codes

A source that meets a confirmatory consultation's criteria may not count as an -other appropriate source- for an outpatient (99241-99245, Office consultation for a new or established patient -) or inpatient consultation (99251-99255). -When a patient requests a second opinion, we currently code the encounter as a confirmatory consult,- says Nicole Tanner, coder at Advanced Healthcare in Milwaukee. But CPT does not consider a patient, family member or insurer an appropriate source for a standard consultation.

To report 99241-99245 or 99251-99255, an appropriate source--such as a physician, counselor, nurse or nurse practitioner--has to generate the request. Under current coding guidelines, a confirmatory consultation's source would fail to meet a consultation's 3 R-s. Physicians could have to report an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient -) instead of a confirmatory consult due to lack of an appropriate requesting source, Tanner speculates.