Problem:

I recently saw a neurologically debilitated patient in the office to address several pulmonary issues. This patient and family have been seen by other members of my group for these problems in the past, but not on a regular basis. They are not compliant with prior recommendations and have changed from pulmonologist to pulmonologist looking for better or different answers and recommendations. This was a new patient to me. I interviewed both parents including their concerns and previously identified respiratory problems. I did a comprehensive Review of Systems, reviewed the Family History, and reviewed the pertinent Past Medical History (including reviewing the considerable medical record). I performed a multisytem examination. I then discussed in detail my impressions and recommendations and answered the families multiple questions. The total encounter time was approximately 55 minutes. The visit was authorized by the primary care provider and a consultative report was dictated and sent. What is the most appropriate E/M code? Office Consultation, Moderate or High Complexity (99244 or 99245); Established patient, Comprehensive or Complex (99214 or 99215); New Patient (99204 or 99205); or Confirmatory Consultation (99274 or 99275)? What's your answer? Please see below for Dr. Jacobson's answer and discussion.

Answer:

99245 - Office Consultation of High Complexity.

Discussion:

If you are being asked to consult on this patient from his PCP and you send a written communication back to the PCP you would use this type of code - office consultation. The only difference between 99244 and 99245 is the level of medical decision making. It is important to first put the ICD-9 code first for the pulmonary condition and then very importantly to also add the neurological condition(s) as well. Part of work in medical decision making are the number of diagnoses.

If time was the factor in the consultation then one needs 80 minutes for 99245 and 60 minutes for 99244. Do not use time except when more than 50% of the visit is case management and counseling.

The confirmatory consultation codes are designed when a second opinion is asked by either the PCP or by the parents. You can use 99215, however, remember the RVU value is significantly less than consultation code. You can not use a new patient code 99205 because the patient was seen by another member of your group within the last three years.