Radiology Coding Alert

Contrary to what many coders believe, more than one physician can bill consultation codes for the same patient on the same day, even if the physicians work for the same practice. The key to reimbursement is ensuring that each physician manages a separate aspect of the patient's care.

By now, most radiology practices are familiar with the three R's of consultations. You should report the consult codes ( 99241 - 99263 ) only if another physician requests the radiologist's opinion, the radiologist performs a formal review (exam) of the patient, and he then sends his opinion or advice back to the requesting physician. Although the three-R's rule is easy to remember and usually simple to apply, it doesn't answer every radiology consultation question.

Jean Hawley, office manager at Atlanta Radiology Consultants, says that her 10-physician practice reports the E/M codes most often when other specialists ask the radiologist whether a patient is a good vertebroplasty candidate. Because her practice consists only of radiologists, she reports the appropriate office consultation code (99241-99245) and sends the radiologist's report back to the referring orthopedist.

Suppose, however, that an orthopedist within your practice evaluates a compression-fracture patient and thinks she might benefit from vertebroplasty (22520-22522). The orthopedist asks you to examine the patient and offer your opinion regarding whether she would make a good vertebroplasty candidate. You evaluate the patient and review an MRI that the orthopedist ordered, and then write a report in which you tell the orthopedist why you think the patient would benefit from vertebroplasty.

You should report the appropriate office consultation code (99241-99245), says Cindy Pack, CPC, CPC-H, an independent reimbursement consultant in upstate New York. "Reviewing the MRI films would be considered part of the medical decision-making component," and you should not report the MRI review separately, Pack says.

The fact that the requesting physician and the consulting physician work at the same practice should not affect reimbursement. Section 15506C of the Medicare Carriers Manual (MCM) states, "Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met."

Suppose an ankle-fracture patient presents to your practice with x-rays from her orthopedist. The orthopedist diagnosed the patient with a trimalleolar ankle fracture (824.6-824.7), requiring open surgical treatment with internal fixation. The patient asks your radiologist for his opinion regarding her diagnosis because she hopes to avoid surgery. The radiologist reads the previous physician's x-rays, examines the patient and concurs with the orthopedist's diagnosis.

According to CMS'consultation reporting standards, this example does not qualify as a consultation because the orthopedist did not request the radiologist's opinion, and the radiologist did not report his findings back to the referring orthopedist.

You should report a confirmatory consultation code (99271-99275) not an office consult for the second opinion. Some carriers deny confirmatory consultation claims, so check with your insurers ahead of time to determine their coverage guidelines and ask patients to sign an advance beneficiary notice (ABN) before performing the service. This way, they know that they will be responsible for payment if the insurers deny the claim. Or, if your documentation supports it, you may be able to report a new patient office visit code (99201-99205) instead.

If the radiologist performs a secondary procedure (such as an MRI) during the initial consultation, you can report both the treatment and the consult as long as you meet the three R's of the consultation. Section 15506B of MCM advises that Medicare will pay for treatment and an initial consultation on the same date unless a transfer of care occurs.

The MCM states: "A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patient's condition should be reported as established patient office visit or subsequent hospital care, depending on the setting."