billing & coding

CARLA MACK, O.D.

Coding for Consultation Visits

Familiarize yourself with these codes for professional referrals.

Once you have a good understanding of applying the new and established evaluation and management codes (see Coding in Jan., March and May 2007 OM), consultation coding becomes simplified. Whenever another practitioner — including other O.D.s, physician's assistants and nurse practitioners — requests you examine a patient, use the consultation codes (99241-99245). The request for your services can be verbal or written, as long as you document appropriately in the patient's medical record.

It's not appropriate to use consultation codes when patients request your services or a second opinion. However, it is appropriate to bill consultation codes when social workers, insurance company representatives and even lawyers make the request.

Consultation requirements

In addition to documenting the consulting request, follow other protocol for proper use of consultation coding. This includes communicating the outcome of the consultation examination back to the referral source in the form of a written report or letter.

The consulting physician can then initiate treatment or order additional tests. Also, report any additional procedures determined to be medically necessary at the initial consulting visit, in addition to the appropriate consultation code.

For example, if I had a written request by a practitioner to assess a patient's corneal health and I determined the patient needed corneal topography and contact-lens fitting at the same visit, our office would code and bill both the CPT codes (92025 and 92310) along with the consultation code. Any subsequent visits to my practice that my patient or I initiate would be billed following the evaluation and management (E/M) coding principles.

Level determination

Consultation codes aren't classified as new or established, but they do use the same three main components of history, examination and decision-making for level determination. You must meet or exceed all three of these components in order for the insurance company to grant a specific level for a visit. This, in fact, is just like the level determination for the new E/M visits.

A documented detailed history, expanded problem-focused examination and straightforward decision-making following the consultation examination leads to a level two, 99242, as the appropriate level consultation examination code. Likewise, you would also code an expanded problem-focused history, detailed examination and low-complexity decision-making as a 99242.

Essentially, the consultation codes are equivalent to the new E/M codes (99241=99201, 99242=99202, 99243=99203, etc.) in level determination, but generally, the reimbursement is at a higher level than the E/M codes. (See "Consultation Codes," right.)

You can easily add consultation codes with a basic understanding of the E/M codes and communication with the referring physician before and after the exam. OM