If there is any way to find a good side to the COVID-19 pandemic, it may be that communicating by means other than face-to-face was both necessary and beneficial to caring for a patient. Believe it or not, some newer CPT codes developed and released by the American Medical Association prior to the pandemic were crucial in this aspect of care.
When needing another’s expertise to help manage a patient, there are two ways: referring the patient or obtaining a consult. Let’s review the practical and legal difference between the two.
Consult. Asking for opinion/advice. A short duration relationship between the consulting physician and patient. Continuity of care that involves the patient returning to the physician who requested consult, and ownership of the patient is still with the requesting physician. Documentation is required by both parties in order to get paid.
Referral. Sending for treatment/care. A long duration relationship between patient and new physician. Continuity of care involves legal transfer of care, and the referring doctor no longer owns the patient. Documentation and patient consent is not required by both parties in order to get paid.
To understand the documentation relationship between the requesting physician and the consulting physician, think of the “three R’s.”
Request. There must be a written order for a consult request in the requesting physician’s patient file.
Render opinion. The consulting physician must formulate an opinion based upon medical expertise and experience and provide it to the requesting physician.
Report. The consulting physician must send a written report back to the requesting physician.
By 2019, the interprofessional consult codes were revised and became covered services by CMS. This allowed physicians to communicate via non-traditional methods for the benefit of the patient.
There are rules to meet the definition of an interprofessional consult, such as:
Billing practitioner. Interprofessional services are limited to those who can independently bill Medicare for E/M services.
Benefit of the patient. Because the patient is going to be responsible for cost-sharing, CMS is concerned about distinguishing Interprofessional Internet Consultations from those undertaken for the edification of the practitioner, such as information shared as a professional courtesy or as continuing education. Verbal consent of the patient must be documented in both practitioners’ medical records, and each provider must collect the requisite copayment as with all Medicare Part B services.
For the requesting physician, there is only one code to use:
• CPT 99452: Interprofessional Telephone/Internet/EHR Referral Service(s) Provided by a Treating/Requesting Physician or Other Qualified Health Care Professional, 30 minutes; $36.60 billed by requesting physician.
For the consulting physician, Interprofessional Telephone/Internet/Electronic Health Record Assessment and Management Service Provided by a Consultative Physician, including a Verbal and Written Report to the Patient’s Treating/Requesting Physician or Other Qualified Health Care Professional, the code sets are:
• CPT 99446: five to 10 minutes of medical consultative discussion and review; $18.81
• CPT 99447: 11 to 20 minutes of medical consultative discussion and review; $33.80
• CPT 99448: 21 to 30 minutes of medical consultative discussion and review; $53.66
• CPT 99449: 31 minutes or more of medical consultative discussion and review; $73.19
For the consulting physician providing just a written report, the code is:
• CPT 99451: Interprofessional Telephone/Internet/Electronic Health Record Assessment and Management Service Provided by a Consultative Physician, including a Written Report to the Patient’s Treating/Requesting Physician or Other Qualified Health Care Professional, five minutes or more of medical consultative time; $36.25 billed by consulting physician.
In a world that is opening up and getting back to normal, physicians and patients alike appreciate making clinical care more efficient and effective, without compromising care; interprofessional consult codes can help greatly.
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Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.