Urology Coding Alert

The words ‘transfer’ or ‘referral’ can be your key to success.

In the midst of keeping up with CCI, ICD-10, and other code set changes, it can sometimes be easy to get comfortable with basic coding foundations – which can then lead to inadvertent errors. Don’t let that happen when you’re faced with a situation involving patient consultations or referrals.

Background: In January 2010, CMS eliminated all consultation codes for office and hospital patient consultations. Many private and commercial insurers quickly followed suit. In place of consultation codes, CMS substituted codes 99201 to 99205 (New patient office or other outpatient visit …) for new office patient consultations and 99212 to 99215 (Established patient office or other outpatient visit…) for established patient office consultations. CPT^® codes 99221 to 99223 for initial hospital care and 99231 to 99232 for subsequent hospital care (for lower level consultations) were substituted for in-hospital consultations codes.

However, there are still a few commercial and private carriers that continue to use the old consultation codes (99241 to 99245 for office and outpatient consultation codes and 99251 to 99255 for in-hospital consultations). When using these latter codes and when we consider referrals, transfer of care, and consultations, some coding confusion may continue to exist.

With the removal of consultation codes and the substituting of office and hospital visit codes, transfer of care and “referral” coding problems really no longer exist to any extent. However, since a minority of carriers still use consultation codes as stated above, let us look at coding problems that may occur even at this late date and let us review the proper use of the older consultation codes.

Know the Terms

A “referral” means that one physician asks another physician to take over a patient’s care before the second physician sees the patient and the second physician accepts the patient for a specific condition that needs treatment, according to Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CPC-I, CCS, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COGBC, COSC, program director Certification Coaching Organization, LLC, in Oceanville, N.J.

“Referral normally implies that all or a portion of the patient’s care will be transferred to a new provider,” adds Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC, in Oceanville, N.J.

Key:  A referral is called a “transfer of care,” and when your provider treats a patient following such a transfer, it clearly leads you to treating your provider’s evaluation and management (E/M) service as a referral, not a consultation. Usually in these cases one should bill CPT^® codes 99201 to 99205.

Code it: Because referrals are a transfer of care, you submit E/M office or inpatient codes to report these services. When referral care takes place in the physician’s office, choose from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...) for new patients and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...) for established patients. Note that these CPT^® codes are the same codes that we now use for billing consultation visits in the office.

Hone In On Legitimate Consultation Opportunities

The consultation codes noted above usually have higher reimbursement rates than similar E/M codes for either inpatient or office services. That means you don’t want to miss a consult coding opportunity when it arises– but you also want to have solid justification for coding the consult.

“In the simplest of terms, any consultation no matter which codes are billed is a type of service where another physician or non-physician practitioner requests a doctor’s advice, opinion, or recommendations about a patient’s problem; that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations,” says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

Remember the Rs: To correctly code a consult, the documentation must reflect three criteria – ‘requested’ opinion, ‘rendered’ service, and ‘reported’ results to requesting provider. If those are not documented, you cannot bill a consultation.

Caution: As stated above, Medicare and many other payers no longer recognize the consultation codes 99241-99245 and 99251- 99255. For those payers, bill an inpatient or outpatient E/M code just like you would for “regular” E/M services (or for referrals, which use the same codes).

At the present time, you should rarely use the specific consultation codes for hospital or office consultations noted above. However, staying aware of the coding guidelines is always a good idea in case an appropriate coding situation arises.