Coding Q&A

Medicare consultation codes no longer used


Medicare “Consultation” Codes Are No Longer Applicable


The year 2010 marks the end of payment by Medicare for consultations as a category of service. There will be a significant loss of income for all retinal physicians, particularly those who practice in an ophthalmology group as a subspecialist. To assist you in salvaging some in come and remaining in compliance, some suggestions are offered here.


Medicare has eliminated from payment the outpatient and inpatient consultation codes. Instructions for outpatient coding state that, when applicable, these patients should be coded as new patients — or established patients if the patient does not meet the criteria for a new patient. The code level depends on medical necessity, complexity of medical decision making, and work performed.

Keep in mind that other insurers may still honor the consultation codes and the classification appears in the CPT manual.

New patients. A new patient is de fined by CPT and Medicare as a patient who has not received any face-to-face services from the practice (not the specific physician in the practice) for three years.

Tips for accurate coding:

► In an older practice, the three years go by very quickly — a great deal of income can be lost if you do not pay attention to the last date of service when coding.
► There is approximately a 40% differential between a new patient and an established patient at a given level of service.
► A patient cannot be coded as a new patient if he/she is referred to an other ophthalmic subspecialist in the same group practice.
► In a retina group, the patient is a new patient only one time (the first en counter) and not again until three years have passed.
► In academic centers, the patient is considered “new” the first time he/she presents to the ophthalmology department.

Intra-office referrals. Retina sub-specialists in a group practice with other ophthalmologists who are not retina specialists will most acutely feel the loss of income caused by the inability to code for intraoffice consultations. Those encounters, formerly coded as consultations, now have to be coded as established patients.

Brush up on your E/M coding and carefully select the code that best suits the circumstances, is in compliance with Medicare rules (especially medical necessity), and optimizes reimbursement.

Since these intraoffice referrals must now be coded as established patients, the basic choices will be between certain E/M codes and certain eye codes.

99214 (E/M Level 4 established patient) vs 92014 (Comprehensive Eye Code established patient). Use code 92014 when coding for comprehensive eye examinations and not for follow-up visits for serious disease.

Use 99214 for follow-ups of serious diseases as long as your medical decision-making is moderate and you have the medical necessity to perform nine of the elements. This code has been a target of OIG investigations and you should be confident of your coding skills and chart documentation when using it.

99213 (E/M Level 3 established patient) vs 92012 (Intermediate Eye Code established patient). There continues to be an approximate $10.00 differential (in favor of the eye code) between these two codes. The examination requirement for intermediate eye code basically is Lids and Adnexa and a slit lamp examination. The E/M level 3 requires six elements and low medical decision making. As long as you perform the requirements for the intermediate eye code, that code may be used.

Audits will be a hot button in 2010, along with the previously de scribed loss of income. It is critically important to code correctly and maintain adherence to compliance rules. RP

Riva Lee Asbell can be contacted at where the order form for her new book Tips on Ophthalmic Surgical Coding by Subspecialty can be found and downloaded under Products/Books.

CPT codes copyright 2009 American Medical Association.