Primary Care Coding Alert

Question: Our provider examined a patient, then provided information about that patient’s condition to another provider on the same day. Is it possible to bill for the office and outpatient evaluation and management (E/M) and the consult on that day? And, if so, do I use 99451 or 99452 to report the consult?

Codify Subscriber

Answer: In this situation, if your provider is providing information about the patient to another provider who requested a consult from your provider, you would not use 99452 (Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes). As the descriptor indicates, 99452 describes a service provided by the requesting physician or other qualified healthcare professional — the other provider in your situation.

You also would not use 99451 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time). CPT^® guidelines preceding codes 99451 and 99452 state that providers must conduct these interprofessional telephone/ Internet/electronic health record (EHR) consultations “without patient face-to-face contact with the consultant” (emphasis added). Your provider, as the consultant, examined the patient, which implies face-to-face contact.

Per CPT^®, assuming the necessary conditions were met (such as a documented request by the other provider and a written report prepared for that provider), you would report the appropriate consultation code reflecting the level of service provided. For outpatient consultations, you would report from among codes 99241-99245 (Office consultation for a new or established patient …).

However, some payers, such as Medicare, no longer recognize CPT^® consultation codes and require physicians and other qualified healthcare professionals to report a different E/M code reflecting the appropriate site of service. So, you should check with your payer to see if you may need to report an appropriate office/outpatient E/M code from among 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) rather than a code from among 99241-99245.