Question

1. Dr. Warren saw Ms. Terry for treatment of a STD. Dr. Warren took Ms. Terry’s history, performed an examination, wrote a prescription and spent 15 minutes counseling Ms. Terry on techniques for reducing her risk of another STD in the future. The entire encounter lasted 20 minutes. Should Dr. Warren’s services be coded as an office visit (99201-99215) or individual preventive medicine counseling (99401-99404)?

2. Ms. Jensen saw Dr. Fret (an internist) for a gynecological problem. Dr. Fret recommended that Ms. Jensen’s problem be treated medically although they discussed surgical options. Four days later, Ms. Jensen decided to consult with Dr. Thomas (an OB/GYN) for a second opinion. Dr. Thomas saw Mrs. Jensen in the office. Dr. Thomas took her history, performed an examination and informed her that he concurred with the treatment plan recommended by Dr. Fret. Dr. Thomas then sent Dr. Fret a letter providing him with her opinion on Ms. Jensen’s condition and treatment. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215), an office consultation (99241-99245), or subsequent hospital care (99231-99233)?

3. Dr. Goodwin (an internist) saw Ms. hurdue. Dr. Goodwin suspected a gynecological problem. Dr. Goodwin called Dr. Thomas (an OB/GYN) and asked her to evaluate Mr. hurdue. Dr. Thomas saw Ms. hurdue in the office. She took Mr. hurdue’s history and performed an examination. She then called Dr. Goodwin and provided him with her opinion regarding Mr. hurdue, recommended a course of treatment and thanked him for the referral. There was no written communication back to Dr. Goodwin from Dr. Thomas. Should Dr. Thomas’s service in the office be coded as an office visit (99201-99215) or an office consultation (99241-99245)?

Answer 1

1. In case of Ms Terry, Dr Warren took Ms. Terry’s history, performed an examination, wrote a prescription which can be considered normal and coded as an office visit. But at the same time it has been mentioned seperately that he spent 15 minutes counseling Ms. Terry on techniques for reducing her risk of another STD in the future which comes under 99401 – Approximately 15 minutes of counseling such as child health, developmental milestones, sexually transmitted infection safety.

2. A consultation is a type of evaluation and management service provided by a physician at the request of another physician. But in case of Ms Jensen, Dr Fret did not recommended Dr Thomas for further evaluation and management service but she herself consulted Dr Thomas for second opinion. Therefore, Dr. Thomas’s services in the office should be coded as an office visit (99201-99215). As far as subsequent hospital care (99231-99233) is concerned there is neither a report of extented review of history or review nor a documentation to support that the patient is stable, recovering, or improving.

3. It is clear case of an office consultation but no written documentation is being performed. If we quote the exact language of CPT about office consultation it is -

'' 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 visit (99201-99215)