Consultation codes bring higher reimbursement

Issue: October 2008

ByCharles B. Brownlow, OD

Charles B. Brownlow, OD, FAAO
Charles Brownlow

Most eye doctors (including doctors of optometry) and most key staff people seem to be pretty confused about when to use the 92000 series ophthalmology office visit codes and when to use the 99000 series evaluation and management services codes.

Become familiar with common codes first

Before branching into other visit codes, such as consultations, I would recommend that all doctors and staff become familiar and comfortable with those other, more commonly used codes. That said, understanding full well that such behavior is not likely, let us discuss “Office or Other Outpatient Consultation” codes (99241 through 99245).

Basically, any time a patient is referred to your office for a specific reason and the referral comes from another health care professional or other appropriate source, and you keep the referring doctor “in the loop” by sending a report to her or him following the visit, the visit may be coded using one of the consultation codes.

CPT requirements for the use of consultation codes
The referral must come from another health care professional or other appropriate source (e.g., social worker, lawyer, insurance company). The request may be written or verbal and must be documented by the referrer in the patient’s record. Until recently, it was acceptable if the patient was referred to you by a family member or friend for a specific reason or suspected condition, or even if the patient “self-referred,” as for a second opinion. Now, unless the referral comes from another physician or “other appropriate source,” you should not use the consult codes and should instead skillfully choose one of the evaluation and management service codes (99201-99215 series) or one of the general ophthalmological service codes (92002, 92012, 92004 or 92014). The visit must be for evaluation and diagnosis only and not for providing care to the patient. It is acceptable to begin care of the patient following completion of the consultation, but that care is appropriately billed using the standard office visit and procedure codes rather than the consultation codes. For example, a patient might be referred to your office by a general physician requesting an eye examination to rule out ocular manifestations of the patient’s systemic diabetes. The visit would be coded as a consultation. If conditions are found during that visit and the patient reappoints with your office for continuing management of those conditions, those follow-up visits and procedures would be billed using the standard CPT codes and not the consultation codes. The doctor providing the consultation is responsible for documenting the reason for the visit and the findings of the visit in the patient’s record and for sending a written report of the findings and recommendations to the referral source. The patient may be sent to your office for evaluation of the same or a potential new problem at a later date and, assuming all the required conditions are met, the consultation code may be used again. This might also pertain to a patient being referred to your office annually for determination of the presence or absence of ocular manifestations of systemic diabetes. Source: CB Brownlow

See the accompanying chart for the CPT requirements for the use of consultation codes. Several considerations and limitations exist.

Based on same components of other 99000 codes

The requirements for choosing a code for a specific office visit or other outpatient consultation are based on the same components as the other 99000 codes: the extent of the case history, the physical examination and the complexity of the medical decision making.

For example, the lowest level consultation service, 99241, requires a problem focused history, a problem focused examination and straightforward medical decision making. The highest level consultation service, 99245, requires comprehensive history, comprehensive examination and high complexity medical decision making.

The “grades” for case history, physical examination and medical decision making are determined using the same definitions as the standard 99000 series office visits, with more specific guidance available by referring to the Documentation Guidelines for the Evaluation and Management Services (1995 or 1997). The Documentation Guidelines were created jointly by the Centers for Medicare and Medicaid Services and the American Medical Association to assist doctors and staff in choosing the appropriate level of office visit based on the content of each patient’s medical record.

Common questions

Many optometrists provide annual ocular health assessments to patients with diabetes at the request of primary care physicians (PCPs). Even if the PCP sends the same patient back to the same eye doctor every year, each of the annual visits can be coded as a consult.

ODs are also often asked by pediatricians to see children who fail vision screenings. While this may fit the letter of the definition, I would not use the consult code for this. It sounds too much like what a normal full comprehensive eye exam should be like – referred in by some attentive professional to another attentive professional to do what the second attentive professional does best.

Many visits qualify for consultation codes

Based on my experience working with eye care practices, it is clear that many visits qualify for the use of the consultation codes, although they are billed using the standard 92000 or 99000 office visit codes. Motivation for doing this type of coding correctly should be that the consultation codes are considered by the providers and by most payers to be more valuable, meaning that a visit that qualifies as a consultation generally has a higher fee and higher reimbursement.

As is true with all coding, becoming familiar with the rules of their use and having proper, current reference materials available within your office will lead to greater peace of mind in every case and enhanced income in many cases.

For more information:

Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board, executive vice president of the Wisconsin Optometric Association and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., P.O. Box 608, Waupaca, WI 54981; (715) 942-0410; fax: (715) 942-0412; e-mail: Brownlowod@aol.com.

CPT 2009 Professional Edition is available from the AMABookstore.com, or as part of Codes for Optometry from the American Optometric Association (AOA) Order Department: (800) 365-2219.

The Documentation Guidelines are available as part of Codes for Optometry from the AOA Order Department: (800) 365-2219, or online at the Centers for Medicare and Medicaid Services Web site: www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp. The guidelines are also available online for members through the AOA Web site by referring to the Medicare Compliance Manual, 2004, or going directly to www.aoa.org/x4754.xml. (Note: The AOA Web site requires a member login using your AOA member number and your password.)