Pulmonology Coding Alert

Question: My pulmonologist had a patient schedule his own appointment and come into the office. The patient said, "Dr. Thomas asked me to see you for evaluation of my chronic cough." Can this be billed as a consultation even though Dr. Thomas did not contact the office himself?


Nevada Subscriber

Answer: Whether you can report a consultation in this case depends on the information in the patient's medical record. To report a consultation code (99241-99245), you must have a documented request by another physician for your pulmonologist to evaluate the patient.

The requesting physician doesn't need to contact your office directly, but you must have written documentation in the patient's medical record that the other physician requested the consultation.

You can contact the other physician's office to verify whether she made a specific request for a consultation. If the doctor simply told the patient he could get a second opinion, it may be possible to report a confirmatory consult (99271-99275), if the visit satisfies the necessary requirements. A confirmatory consult is a "second opinion" requested by the patient, family, or other third party. The physician may only provide an opinion or advice. If he provides any treatment or additional testing, the physician cannot report a confirmatory consult code, and instead should report a new patient visit (99201-99205).
 
Know the Three R's: There are three criteria for a consultation, known as the "Three R's," that your doctor needs to satisfy. The request for the consultation is the first. In order to report outpatient consultation codes (99241-99245), a physician or "other appropriate source" (e.g., NP, PA, resident) must request an opinion or advice from the consulting physician. The consultant should document the request for service. This could be noted in a letter that's sent back to the requesting physician.

Second, the consulting physician needs to record his findings, opinions, and advice in written form in the patient's medical record.

Third, the pulmonologist must submit a written report to the requesting physician. Both the requesting physician and the pulmonologist should keep a copy of this report. Be sure that the pulmonologist satisfies each of these three criteria before you submit a consultation code.