Pulmonology Coding Alert
Consultation Criteria
Nevada Subscriber
Answer: A few factors must be considered to determine whether this is a consultation:
1. You have satisfied the first criteria in that a consultation (99241-99245) must be at the direct request of another physician the PCP requested the consult from the pulmonologist. The pulmonologist should document this in the patients medical record by indicating that the visit is a consultation at the request of Dr. X. Or, when the pulmonologist writes the letter back to the requesting physician (see #3 below), he or she can write, Thank you for allowing me to see your patient in consultation or I had the pleasure of seeing your patient in consultation.
2. The second factor depends on the intent of the visit. If the PCP feels that the care of this problem should be provided by the pulmonologist only, and there is a transfer of care prior to the visit with the pulmonologist, the visit is a new patient visit (99201-99205). If the PCP is sending the patient for the pulmonologists opinion on how to manage the patient, and he will return to the PCP for continued treatment, it is a consultation. When reporting the consultation codes, the pulmonologist may initiate treatment for the persistent cough and may authorize a follow-up visit to evaluate the response to treatment. The follow-up would be coded as an established patient visit (99211-99215).
3. The opinion solicited from the pulmonologist by the PCP must be communicated back to the PCP. The pulmonologist must send a letter back to the requesting physician outlining the recommendations for care.
If you fulfill these requirements, bill the visit as a consultation. Otherwise, code it as a new patient visit.
Answers to You be The Coder and Reader Questions provided by Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania in Philadelphia; and Mary Mulholland, RN, CPC, reimbursement analyst with the Hospital of the University of Pennsylvania.
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