Jennifer Swindle


Is the new patient you’re seeing today a referral or a consult? Are you sure? 

Evaluation and management (E&M) consultations are reimbursed at a higher level than new-patient E&M visits of similar complexity. This serves in part to compensate you for the extra effort entailed in writing a report to the referring provider. But the patient’s medical record has to show that your visit is indeed a consult for you to be properly reimbursed. 

You must document three critical elements to support billing a patient visit as a consultation. 

First, you have to make clear that the visit is the result of a direct request from another provider. That is, a physician or other healthcare provider must ask for your evaluation and/or opinion of a patient’s specific symptom or condition for a visit to qualify as a consultation. Ideally, this request should be made in writing and be incorporated in the patient’s medical record. In all cases, the medical records for that patient kept by both you and the referring provider must cite the request. 

Second, a consultation consists of only an evaluation and/or opinion; it may not involve a transfer of care before the visit occurs. If another physician transfers a patient’s care to you for a specific problem or concern, any subsequent visits with that patient are not consultations. Both your records and the referring provider’s records should clarify that the request for consultation is for evaluation and opinion purposes only. 

Finally, you must forward a written report after your consultation to the provider who requested it. The report should include a review of the specific problem or concern you were asked to evaluate, the steps you took to evaluate it, and your findings, conclusions, recommendations, and/or opinion on the case. Include any documentation, such as test results, patient history, and exam notes. 

Completing these steps does mean additional work - but you will be compensated at a higher rate. 

Of course, different types of consultations call for different levels of service. 

Service-level requirements for E&M consults are identical to those for corresponding new-patient E&M visits. For example, the requirements for both E&M consultation code 99244 and new-patient code 99204 include a comprehensive patient history, a comprehensive examination, and moderate-complexity medical decision-making. As with a new-patient visit, when performing a consult, you must document these three services to justify a given service level. 

However, consult visits are held to stricter standards than are the much more common established-patient visits. A consultation visit that includes a comprehensive exam and moderate-complexity decision-making, but not a detailed patient history, qualifies as a 99243 rather than a 99244 code. Established-patient visit rules call for meeting only two of the three documentation requirements to justify a specific level of service. 

Jennifer Swindle, RHIT, CCS-P, CPC, CCP, EMS, 

is the senior coding consultant for PivotHealth LLC (www.pivothealth.com), a Nashville-based management and consulting firm specializing in medical group management, hospital-physician relations, patient/provider/staff satisfaction surveys, physician compensation plans, strategic planning and leadership, revenue growth enhancement, coding and compliance reviews, and many other medical group operations. She can be reached at 

This article originally appeared in the May 2007 issue of

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Tips from our biweekly e-mail newsletter. This issue: Consult or referral? Documentation is critical.

Coding: Your Top Coding Concerns Solved


The most common service billed in primary-care offices covers evaluation and management (E&M) visits. But you also perform many minor medical procedures in your office that can be billed separately. They must be correctly documented and coded, however. Here’s how to bill some common minor office procedures:

 - The code 69200 refers to the removal of a foreign body from an external auditory canal without general anesthesia. Medicare pays more for this procedure than it does for a new-patient visit. After treatment, be sure to document the object removed, its impact on your patient, and the instruments you used. The code 30300 applies to the removal of an intranasal foreign body. To complete the documentation, record the type of foreign body removed, its location, and your approach to performing the procedure. 

 - The code 29130 covers the application of a static finger splint. When you identify a fracture, you send the patient to an orthopedist for fracture care. But you can bill for applying a splint to stabilize the fracture in the interim for pain control. Document how you detected the fracture, the way you treated the fracture in the interim and your reasons for choosing that treatment, and where you referred the patient for additional treatment. The code 24640 refers to reducing radial head subluxation. When coding for this procedure, be sure to document your patient’s symptoms and any X-rays you used to diagnose the injury.

 - The code 69210 indicates the removal of impacted cerumen. You can often bill this fairly common procedure separately from an office visit. Note, however, that merely flushing a patient’s ears does not justify this code. You must use instrumentation and document why you determined that this procedure was necessary. Removing impacted earwax is not billable if ancillary personnel perform the service.

 - The code 99173 refers to visual acuity screening, and the code 92551 applies to pure-tone hearing screening. While Medicare does not cover these services, many private payers do. 

To avoid confusion and duplicate billings, your coding sometimes needs to specify where you did something - was that the lesion on the toe or the back? Here’s the scoop on location modifiers and when to list them. 

 - Use modifiers -FA through -F9 and -TA through -T9 to designate the 10 toes and fingers, starting with A for the left big toe and thumb, and then 1 through 9 for the rest. Report each service separately. For example, if six toes require surgery to repair hammertoes, cite the code six times, identifying each toe treated. 

 - List the modifier -50 when you perform the same procedure on paired organs on both sides of a patient’s body (e.g., a bilateral knee replacement). When using -50, report the procedure code only once; the modifier indicates that it was carried out on both sides of the body. 

 - Cite the modifiers -RT and -LT to indicate the side of a patient’s body on which you worked. These modifiers can also designate the locations of similar procedures done at the same time on two different locations on a patient’s body. For example, you might remove lesions from both the right and the left sides of a patient’s back. When you pair the modifiers -RT and -LT, you need to enter the procedure code twice, once for each side. Some payers prefer to see the -RT and -LT modifiers rather than the -50 modifier to indicate bilateral procedures. Ask your payers about their preferences. 

, a senior coding 
consultant for PivotHealth LLC (

), a Nashville-based management and consulting firm. She can be reached at 

For more coding tips, sign up for our biweekly newsletter, “Physicians Practice Pearls on Coding,” at 

This article originally appeared in the March 2007 issue of

Tips from our twice-a-month e-mail newsletter. This issue: documenting minor office procedures.

Coding: Your Top Coding Problems Solved


There are nearly 40 ICD-9 codes for reporting diabetes disease processes. You have to document very specifically and consistently if you and your staff are going to choose the right one. 

Here’s how ICD-9 diabetes coding works:

 are the diagnostic code category “250,” indicating diabetes mellitus.

 identifies whether clinically significant manifestations exist and, if so, which body system is affected.

 indicates the type of diabetes (1 or 2) and whether it is controlled or uncontrolled. 

Coders and billers must have all this information to pick the right code. 

When documenting, record “Type 1” or “Type 2” diabetes rather than “insulin dependent” or “non-insulin dependent.” 

It’s also important to indicate in the patient’s chart whether the diabetes is controlled or uncontrolled. Uncontrolled means that the current treatment regimen does not keep the patient’s blood sugar level within an acceptable range. If this is the case, you should include the term “uncontrolled” or some comparable documentation note in the diagnosis portion of the record. Merely listing blood sugar levels is not enough. 

 
Before selecting a diagnosis code, make sure your patient’s medical record shows when a medical condition is a result of diabetes. For example, for patients with a diabetic cataract, don’t list just “cataract.” Instead, specify “diabetic cataract.” This clarifies that diabetes is the underlying cause. 

If another medical condition is caused by diabetes, the diabetes must be coded first because it is the primary disease process. The manifestation is a secondary diagnosis. For example, here’s how diagnosis coding breaks down for a patient who has controlled Type 2 diabetes and has developed a diabetic cataract:

 The “250” refers to diabetes mellitus; the “5” indicates an ophthalmic manifestation; and the “0” captures that it is Type 2 and controlled. 

 It is reported to explain the “5” in the first diagnosis. The “366” designates a cataract; the “4” indicates that the cataract is associated with another disorder; and the “1” spells out that the other disorder is diabetes. 

 
Modifier -25 is the most common evaluation and management (E&M) modifier. Use it right, and you’ll get paid more. 

 Medicare requires a modifier -25 for an E&M service that is performed on the same day as a procedure that has a “global fee” period. Commercial carriers might also require it for services that have no global period. 

The E&M and the procedure don’t have to be associated with separate diagnoses. All that matters is that you provide a separate and significant E&M service. That means you did more than the normal pre- and post-operative steps. Your documentation has to support both services. 

procedure visits include a “mini E&M” service. For example, before removing warts, you might ask the patient some questions, look at the area, and discuss the procedure. That is not a separate and significant E&M service; it’s part of the procedure. It does not meet documentation guidelines for an office visit. 

Many payers believe -25 is widely abused, so they often challenge claims reporting it. If you understand the rules, you’re in a better place to battle back. 

 Jennifer Swindle, RHIT, CCS-P, CPC, CCP, EMS. 

She is a senior coding consultant for PivotHealth LLC, a Nashville-based management consulting firm specializing in medical group management, hospital-physician relations, patient satisfaction surveys, physician compensation, strategic planning and leadership, revenue growth enhancement, and coding and compliance reviews. She can be reached at 


For more coding tips, sign up for our biweekly newsletter, 

“Physicians Practice Pearls on Coding.”

This article originally appeared in the January 2007 issue of

Tips from our biweekly e-mail newsletter.

Author | Jennifer Swindle

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