Answer: This is a two-part office visit scenario. The first part of the scenario illustrates the original new patient office visit, and the second portion is for the follow-up, interprofessional telephone consultation with the patient’s ophthalmologist.
For the office visit …
CPT: 99203
ICD-10: B30.8, M45.5, I73.00
- The history was detailed, because the history of present illness was extended, the review of systems was extended and the past family history was complete.
- The exam was comprehensive.
- The medical decision making was of moderate complexity, because it was an undiagnosed new problem with uncertain prognosis.
This is a new patient visit; therefore, the history, exam and medical decision making are all considered when determining a level. The history was only a detailed level so this means the visit cannot be higher than a level 3 visit.
For the consultation follow-up …
CPT: 99451
ICD-10: B30.8
Coding Rationale
Although not common to rheumatology practices, as of January 2019, the Centers for Medicare & Medicaid Services allows for reimbursement of interprofessional telephone, internet and electronic health record assessments for management services provided by a consultative physician. This could include a written report to the patient’s treating physician or other qualified healthcare professionals. According to coding guidelines, the call has to include five minutes or more of medical consultative time.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.