This encounter is coded as 99204 because it included:
- A comprehensive history: Extended history of present illness, complete review of systems, and complete past family and social history;
- A comprehensive examination: 12 systems; and
- Moderate complexity decision-making: New problem with uncertain prognosis (primary or secondary Raynaud’s phenomenon), extensive laboratory studies ordered, and prescription medication therapy initiated.
The visit would be considered a new patient visit, rather than a consult, because there is no evidence showing that the referring doctor is requesting the rheumatologist’s medical opinion or advice.
Just because a patient states that he or she was referred by a PCP does not mean the referring doctor is asking for the rheumatologist’s expert advice. A referral could be needed for insurance requirements. To bill for a consult, the patient’s medical record must include a request from the PCP stating there was a need for the rheumatologist’s medical opinion or advice. This should be in the PCP’s medical record, but you cannot rely on that. In order to protect yourself from an audit, it should be in your patient’s medical record. Physicians are increasingly finding themselves being down-coded in this situation during an audit.
The ACR suggests that its members take proactive measures to ensure that there is documentation in their patients’ medical records to support the billing of a consultation. To obtain tools to assist you in coding, visit www.rheumatology.org/practice and click the Documentation and Coding link. For additional information, contact Melesia Tillman, CCP, CPC, ACR coding and reimbursement specialist, at (404) 633-3777, ext. 820 or [email protected].
