Primary Care Coding Alert

Question: I work in a large family practice group (single specialty). Because I am a family physician with a surgical background, I perform numerous office procedures. My colleagues often refer their patients for consultations of skin cancer (malignant excision with flap closure), hemorrhoids (infrared or hemorrhoidectomy) and large lipoma (tumor excision). For the initial evaluation of the patient's condition, should I use consultation codes?

Illinois Subscriber
 
Answer: You may report a consultation code if the visit meets the consultation criteria. Per CPT, a consultation is "a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." A consultation also requires a written report back to the requesting physician or other appropriate source.

If your colleagues request your opinion or advice regarding the evaluation and/or management of the conditions that you describe, you may be able to code your initial encounter with the patient using the appropriate consultation code (such as 99241-99245, Office consultation for a new or established patient ...) as long as you document the request in the patient's medical record and provide a written report back to the colleague who requested your advice/opinion. (Be aware that insurers may reject a consultation code from a physician in the same specialty and practice.)

But if your colleagues simply refer the patients to you for performance of the designated procedure (that is, your fellow FPs aren't requesting your advice or opinion on evaluation and/or management of the problem), you shouldn't code the initial patient encounter as a consultation. Instead, you should use another appropriate E/M code, such as an office visit code (e.g., 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), because the referral represents a transfer of care instead of a true consultation.