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Pulmonology Coding Alert

Solve the Consultation Mystery

Published on Sat Feb 01, 2003

Even if you've never directly diagnosed one of your patients with hypersensitivity pneumonitis (HP), you've probably offered your consultative services to a primary-care provider (PCP), so you need to freshen up on how to get the most out of your consultations with HPpatients.

Pulmonologists usually consider HPas a diagnosis, but generalists occasionally miss it, says Anthony Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee. Therefore, PCPs commonly request consultations from pulmonologists for patients with these symptoms.

A patient will often present to his PCPwith a persistent cough, abnormal pulmonary function test (PFT) results, abnormal x-rays and a positive methacholine test, Marinelli says. The PCPmay be quick to diagnose asthma, which has similar symptoms and test results. As a pulmonary specialist, however, you will consider other possibilities in your consultation report that correlate with a positive methacholine test and always take context into consideration. You can report your services and receive proper reimbursement for your time by using consultation codes 99241-99255.

According to CPT guidelines, a consultation is a service provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or other appropriate source. "The service needs to be requested by a physician who is coming to the specialist wanting his opinion on that patient's condition," says Lisa Clifford, CPC, owner of the multispecialty coding firm Clifford Medical Billing Specialists in Naples, Fla. Remember three points when reporting consultations:

  • The written or verbal request for a consultation must be identified in the patient's records.

  • The consulting physician must document his opinion in the records, along with services ordered or performed, and communicate this to the referring physician in a written report, Clifford says.

  • You can report a consultation code when the consultative service is between the same specialty in the same group practice and the above criteria are met.

    Do not get consultations confused with referrals. A referral is defined as a documented complete transfer of care from the PCP to the pulmonologist prior to the pulmonologist's service being rendered.

    In most cases, a pulmonologist will use the office or other outpatient consultation codes 99241-99245. Any follow-up consultative care that meets the above guidelines should be coded in the office or other outpatient services category for established patient visits 99211-99215.

    Remember that the consulting physician may initiate diagnostic or therapeutic services at the first or subsequent visits. When the consulting physician assumes responsibility for all of the patient's care, you should report the E/M services provided after the initial consultations using the appropriate level of subsequent hospital care (99231-99233) or office or other outpatient services (99211-99215). Use 99261-99263 for any other follow-up inpatient consultative care.

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