Primary Care Coding Alert

When your family physician (FP) examines his own patient for surgical clearance, dont miss the perfect opportunity to use the higher-paying consultation codes (99241-99245). Because the surgeon requests the FPs opinion, the preoperative exam qualifies as a consultation if the FP states the reason for the request and issues a report of his findings to the surgeon.

99242 Allows You to Recoup an Extra $38

Many practices lose out on this deserved revenue, however, by reporting an office visit, such as 99213 (Office or other outpatient visit for an established patient 15 minutes face-to-face) or 99214 ( 25 minutes face-to-face). But the consultation codes, for instance 99242 (Office consultation for a new or established patient 30 minutes face-to-face) and 99243 ( 40 minutes face-to-face), pay much more. When I started working at the clinic, preoperative exams were mostly being coded as 99213 or sometimes 99214, says an office supervisor of a family practice clinic in Illinois.

After the office supervisor presented some documentation to the director and physicians, the clinic now uses 99241-99245 for the exams. Financially, there is definitely a difference in the reimbursement, the family practice supervisor in Illinois says. In fact, 99213 pays $37.16 less than its consultation equivalent 99242, based on national Medicare allowances. Because the physicians do the work for a consultation, they deserve to be paid for it, she says.

Similar Elements Comprise 99213 and 99242

In fact, despite the revenue disparity, 99213 and 99242 basically require the same elements. Code 99213 requires two of three components expanded problem-focused history, expanded problem-focused examination, and/or low-complexity medical decision-making. CPT specifies the same history and examination requirements for 99242 but allows straightforward medical decision-making. Note that 99242 requires all three components.

The following typical preoperative exam example qualifies for either 99213 or 99242: An ophthalmologist requests that an FP clear a 65-year-old hypertensive patient (401.1, Essential hypertension; benign) for cataract surgery. The FP performs an expanded problem-focused history, expanded problem-focused examination and straightforward medical decision-making.

In this situation, you should choose 99242 for the FPs service. If, however, you choose the office visit code (99213, which contains 1.39 relative value units [RVUs] and reimburses $51.14) instead of the consultation code (99242, which has 2.4 RVUs and pays $88.30), you will cost your practice $37.16 per visit, based on the Medicare Physician Fee Schedule Relative Value File.

Some consulting experts estimate that the average FP performs four to five preoperative exams a week. That means using 99242 instead of 99213 may sacrifice almost $200 in revenue per week.

CC, Findings Contain Consultation Requirements

 To gain this ethical extra revenue, make sure the visit meets the three Rs of a consultation, says Heather Findlay, CPC, CCP, patient accounts supervisor and coding specialist for Family Health Centers in Okanogan, Wash. Use a consultation code when the patients medical record shows:
 
  the surgeon requested the FPs opinion
  the reason for the request
  a written report to the surgeon describing the FPs findings.

You may have to look under different headings to find the three Rs. The FP usually documents the first two items in the patients chief complaint (CC). The reason for the encounter (CC) is why the surgeon is asking for the FP to perform the preoperative exam, Findlay says. Use the patients underlying condition that prompted the need for surgical clearance, she says. Otherwise, the insurer may deny the exam as not medically necessary or may deem the service a duplication of the surgeons service.

For instance, if the physician states in this documentation that Ms. Jones seen at the request of Dr. Smith, who is requesting preoperative clearance due to hypertension, this will help the payer see that the FP exam is medically necessary, Findlay says. The ophthalmologist requests the FPs opinion on whether the patients hypertension is stable enough for the patient to endure the surgery.

The FP must issue a written report to the surgeon of his findings, stating that in his opinion the patient is fit to undergo the inherent risks of surgery and anesthesia. Look for the FPs findings under impression and plan in the medical record.