Question

1.) Dr. Johnson (an internist) saw Ms. Bane. Dr. Johnson suspected a gynecological problem. Dr. Johnson called Dr. Thomas (an OB/GYN) and asked her to evaluate Ms. Bane. There was no written request sent to Dr. Thomas by Dr. Johnson. However, based on Dr. Johnson’s verbal request (which was documented by Dr. Thomas and Dr. Johnson in each of their medical records), Dr. Thomas saw Ms. Bane in the office. She took Ms. Bane’s history and performed an examination. She then wrote Dr. Johnson and provided him with her opinion regarding Ms. Bane, recommended a course of treatment (which was filed in Ms. Bane’s medical record) and thanked him for the referral. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215) or an office consultation (99241-99245)?

Same as above except Dr. Thomas also wrote a prescription for Ms. Bane and made a follow-up appointment for Ms. Bane to see her again in three days. Should Dr. Thomas’s initial services (not the follow-up visit) be coded as an office visit (99201-99215) or an office consultation (99241-99245)? Same as above. At the conclusion of the follow-up visit, Dr. Thomas wrote Dr. Johnson again providing him with an update on her opinion regarding Ms. Bane. Should Dr. Thomas’s follow-up services be coded as an office visit (99211-99215) or an office consultation (99241-99245)?

Same as above except a week later Dr. Johnson saw Ms. Bane again. He was concerned that her condition had not cleared up so he called Dr. Thomas and asked her to reevaluate Mrs. Bane and provide an updated opinion. Dr. Thomas documented Dr. Johnson’s verbal request and saw Ms. Bane in the office. She took Ms. Bane’s history and performed and examination. She then wrote Dr. Johnson and provided him with her updated opinion regarding Ms. Bane and recommended a revised course of treatment. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215) or an office consultation (99241-99425)?

Answer 1

1. An office consultation is a service in which thorough evaluation and management of a patient is performed by a specialist doctor on the request of another physician because the first doctor is not sure about the exact medical condition and seek for a second opinion. Here in case of Ms Bane, it is a clear case of an office consultation. However, no written documentation is being performed. But, both the doctors mentioned it in the patient medical record and according to the exact language of CPT about office consultation -

'' The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source.''

So in my opinion it will be coded as an office consultation (99241-99245)

2. Ms Bane first visit to Dr Thomas should be coded as an office consultation (99241-99245) because it was Dr Johnson who recommended Dr Thomas to Ms Bane and it was not just an office visit. Secondly, the follow-up visit should be coded as an office visit (99211-99215) because the second visit was not recommended by Dr Johnson and it was Dr Thomas who herself asked for a follow up visit.

3. In the third scenario, Dr Johnson asked Dr Thomas to reevaluate Mrs. Bane responding to which Dr. Thomas documented Dr. Johnson’s verbal request and saw Ms. Bane in the office. She took Ms. Bane’s history and performed examination and recommended a revised course of treatment. All the events fulfill the criteria of office consultation and hence should be coded as (99241-99245)