coding strategies

Billing for Consultations: Leveraging Your Expertise

BY CLARKE D. NEWMAN, OD, FAAO

If you start having success prescribing medically necessary contact lenses, then you're likely to develop a reputation that will bring in a referral or two. Sometimes colleagues will transfer the care of a patient to you, and sometimes they just want your help with a difficult case.

When another practitioner wants your help with a difficult case, this service is considered a consultation. Such consultations are contemplated to be more difficult than your standard examination and are reimbursed at a significantly higher level.

Consultation Qualification

When your service meets the requirements for a consultation and you bill a routine service, you're not recouping the reimbursement justified for that care. We decided in January that we weren't going to do that anymore.

Conversely, billing for consultations when the requirements aren't met is unethical and a breach of contract with the payer. If the payer is the government, then you're committing fraud, which is a criminal offense.

So, it's important that we learn to use these codes correctly. Once again, there is much out there that passes as practice management advice, and, as I've said before, it doesn't matter what guys like me say unless we can back it up with proof.

For consultations, as it does with all codes, the proof lies in the plain language of the CPT code itself. Further, there are clarifying examples offered by CPT and in the PUB 100 references promulgated by CMS.

First, we're talking about the five levels of Office consultation codes (99241-99245). These codes strictly follow the level guidelines for the E/M codes. There is no distinction between new and existing patients. You might argue that you can't do a consultation on an existing patient, but it's happened in my practice. CPT specifically states "New or Established" in the guidelines; they think it's okay to bill a consultation on an existing patient.

Documenting and Billing

A physician, PA, nurse, DC, PT, OT, speech pathologist, psychologist, social worker, lawyer or insurance company may request a consultation. You may bill a consultation only once per patient per distinct condition. The request may be verbal or in writing. Always document the request in the record because without it, you don't qualify for a consultation.

Further, you cannot bill a consultation on a patient who was referred to you, because a referral implies a transfer of care. However, if a patient who has come to you under a consultation elects to stay with you as your patient, you can ethically bill a consultation on the first visit. If a referring source transfers the care, then you should bill E/M codes or the general ophthalmological codes.

It's a myth, however, that once you bill a consultation code that you cannot see that patient a second time. A consultation may take several visits before you can make the final recommendation. These issues are covered in the PUB 100 section for consultation codes (CMS Publication 100-4, Chapter 12, Section 30.6.10, cms.hhs.gov/manual/downloads/clm104c12.pdf).

You should bill all follow-up visits as E/M services, according to PUB 100-4, 12, 30.6.10.C. Remember, a written report is also a requirement. An e-mail is sufficient if it's documented in the patient record.

Use the Codes Correctly

So, let's start using the consultation codes correctly and ethically, and we will improve our bottom lines. Next month, more on billing for services! CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery.