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Medical Coding in a Consulting Capacity


This month's coding questions look at the difference between a 99243 vs 99244 in a consulting capacity.

 Q:  I am a family medicine provider with a sports medicine fellowship. Can you give me some guidance on the difference between a 99243 vs 99244 in my consulting capacity - other than time? Please answer the questions as they pertain to my dual roles (see below).

Answer:   First off, the key to documenting any consult remains documenting the request for the consult "Pt seen in consultation at the request of Dr. X for __________" Substitute the problem, or the context etc.

Once that's done, you need to be sure that there is some documented indication that the findings were shared with the requesting provider (cc'd, faxed, messaged etc.) if the provider does not have a shared medical record with you. You absolutely need to have those two foundational pieces to support a consult.

Then you need to be sure it is a consult - someone is seeking your opinion or advice. That needs to be very clear - not 'referred by', 'to manage' etc. 

Assuming that you have a decent history of present illness (HPI), and you need to watch these on pre-ops (you do still need to document the problem, how long, how bad, etc.), and the mechanical elements of review of systems (ROS), Past Medical, Family and Social History (PMFS), and exam are there - then like any other E&M visit it's about decision making.

 1. Sports medicine would be along the lines of orthopedics: looking at images vs just reading reports, doing procedures during consultant visit.

 For sports medicine visits, one could assume that this would be for a worsening or unknown problem. Make that clear - say that it's worsening, progressing, exacerbated. The fact that a problem needed an intervention would suggest this. One stable and one worsening problem is moderate medical decision making (MDM) versus low (4 vs. 3). Three stables vs. two stables is also moderate vs. low. New issues with differential diagnosis (DDx) are 4s, usually with some advanced diagnostics. The comment about looking at images vs. reading the report is a documentation point you want to include when applicable, it does get you an extra point on the data table. Also think of problems that cause moderate functional impairment, ruptures, tears and other potentially long-term problematic issues as more level 4s -specifically mention the DDx, the risk, and the concern. 

2. Internal medicine is mostly for pre-op clearance: review labs, EKG, chest x-ray, etc.

For the pre-op versions of consults, again, watch the HPI - which is often missed. If the patient has three or more chronic problems, this is most easily addressed by giving the status of these chronic problems - meds, last labs etc. in the HPI - then making sure the attending physician (A/P) spells out those same problems  (with their status, after study). Be sure to say [whether or not] the patient's conditions are stable. Also, this is the place to indicate that the patient is a low-to-moderate risk for the surgery.

 If the patient has one or two stables - it's likely a level 3, if they have three or more, or other documented risk factors - level 4.

Q: I have been reporting CPT code 99406 for my doctors and I keep getting a rejection. Using DX code F17.200. What DX code should I be using in order for this to be paid?

A:  We always wonder when someone says that they keep getting a rejection, do you mean that all of these are being rejected, or one particular claim?

Before you give up on this CPT or others - try an ICD.10 code that isn't unspecified - F17.210 Nicotine dependence, cigarettes, uncomplicated. 99406 is pretty strict in needing F17.210 as the diagnosis. Other codes often trigger an edit.

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