More and more practices are adding Mohs surgeons or incorporating this vital surgical option to the list of services offered. As such, the need to understand all aspects of coding Mohs and Mohs-related services is important, if not critical. Not only could miscoding result in the loss of significant revenue, as Mohs is extremely profitable, incorrect coding could also trigger audits as these services are highly monitored.
In this article, we will concentrate on the consultation visits billed in conjunction with a Mohs procedure and what your practice should know about billing these types of evaluation and management services.
Some Basics
1. The intent of a consultation service is that a physician or qualified non-physician provider (NPP), or other appropriate source, is asking another physician or qualified NPP for advice, opinion, recommendation, suggestion, direction, or counsel in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.
2. Carriers will pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consultant physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.
A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice.
3. NPPs may request a consultation from a provider or an appropriate source. The consultant may be in another practice or part of his/her group. The NPP may bill a consultation if all the criteria for a consultation are met.
4. The documentation requirements for NPPs are the same as the requirements for physicians. In order to justify the billing of a consultation, the following criteria must be met.
a. The consultation service must have a written request from the requesting provider.
A consultation request may be verbal; however, the verbal interaction identifying the request and reason for a consult must be documented in the patient’s medical record by the NPP or physician who requested the consult and also by the consultant physician or qualified NPP in the patient’s medical record.
b. The consultation evaluation service must be performed.
c. A written report to the referring provider must be in the medical record.
5. NPPs must meet the collaboration and physician supervision requirements as required per state law and carrier requirements. A physician assistant must meet the general physician supervision requirement.
6. Physicians and qualified NPPs may not bill a consultation service as a split/shared evaluation and management service.
7. In an office or outpatient setting, another consultation may be requested of the same consultant NPP if the consultant has not been providing ongoing management of the patient for this condition after his/her initial consultation.
Levels of E/M Services
One of my greatest concerns regarding Mohs surgeons billing for consultation services is not the fact that they bill consultations, it is the high levels of care that are often billed.
Let’s make some basic assumptions here so that the basis for my concerns is understood.
1. A provider, who is not a Mohs surgeon, refers a patient to the Mohs surgeon for evaluation of a recurrent lesion — let’s say for a skin cancer in an area where the loss of normal tissue must be minimized, or one that has ill-defined borders. A host of other medical necessity reasons exist, but these two seem to be the most common.
2. In most cases, the Mohs surgeon will treat the patient on the same date of service that the consultation is performed. Therefore, in most cases the Mohs surgeon’s office schedules enough time to perform the surgical service.
3. The Mohs surgeon has some basic knowledge of why the patient is being referred. The Mohs surgeon is expected to evaluate a specific lesion(s), determine the appropriateness of performing Mohs based on the size, location and nature of the lesion(s), and then, in most cases, proceed to remove the lesion(s) using the Mohs micrographic technique.
So here is my concern. Why are so many Mohs surgeons billing consultations with level two and three codes (e.g., 99242 and 99243)?
What Is Required for a Level-Two Consultation (CPT Code 99242)?
1. History Components
a. one to three HPI factors (history of present illness)
b. one review of systems (ROS) related to the chief complaint.
2. Examination Components
Examination of six or more body areas.
3. Medical Decision-Making (MDM)
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
What Is Required for a Level-Three Consultation (CPT Code 99243)?
1. History Components
a. four or more HPI factors
b. two to nine ROS related to the chief complaint
c. one to three PFSH (past, family or social history).
2. Examination Components
Examination of 12 or more body areas.
3. Medical Decision-Making
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
Justifying Medical Necessity
Based on the above information, you now should start to see the problem. What is the justification for examining six or twelve body areas when the patient is being referred to you, the specialist, for evaluation of a specific problem for which you most likely will do surgery? Is it medically necessary to do a full-body exam when the only reason the patient is being referred to you is for the removal of a single lesion on the nose? (I realize that sometimes there is more than one site; but rarely six!)
Obviously, the physician will have to perform a preoperative history and examine the site(s), but extended or comprehensive body checks are inappropriate; especially when the majority of the cases are being sent by other dermatologists (many within their own practices) many of who discovered the skin cancer when performing full-body examination. Most carriers would consider this duplication of effort medically unnecessary.
E/M visits continue to be the target of many focused audits. Dermatologists and Mohs surgeons alike will need to carefully monitor the levels of care billed for their consultation service.
Below are the statistics for dermatology utilization of consultations based on CMS data for 2005:
CPT code 99241 12.16%
CPT code 99242 49.83%
CPT code 99243 34.81%
CPT code 99244 2.94%
CPT code 99245 0.26%.
More and more practices are adding Mohs surgeons or incorporating this vital surgical option to the list of services offered. As such, the need to understand all aspects of coding Mohs and Mohs-related services is important, if not critical. Not only could miscoding result in the loss of significant revenue, as Mohs is extremely profitable, incorrect coding could also trigger audits as these services are highly monitored.
In this article, we will concentrate on the consultation visits billed in conjunction with a Mohs procedure and what your practice should know about billing these types of evaluation and management services.
Some Basics
1. The intent of a consultation service is that a physician or qualified non-physician provider (NPP), or other appropriate source, is asking another physician or qualified NPP for advice, opinion, recommendation, suggestion, direction, or counsel in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.
2. Carriers will pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consultant physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.
A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice.
3. NPPs may request a consultation from a provider or an appropriate source. The consultant may be in another practice or part of his/her group. The NPP may bill a consultation if all the criteria for a consultation are met.
4. The documentation requirements for NPPs are the same as the requirements for physicians. In order to justify the billing of a consultation, the following criteria must be met.
a. The consultation service must have a written request from the requesting provider.
A consultation request may be verbal; however, the verbal interaction identifying the request and reason for a consult must be documented in the patient’s medical record by the NPP or physician who requested the consult and also by the consultant physician or qualified NPP in the patient’s medical record.
b. The consultation evaluation service must be performed.
c. A written report to the referring provider must be in the medical record.
5. NPPs must meet the collaboration and physician supervision requirements as required per state law and carrier requirements. A physician assistant must meet the general physician supervision requirement.
6. Physicians and qualified NPPs may not bill a consultation service as a split/shared evaluation and management service.
7. In an office or outpatient setting, another consultation may be requested of the same consultant NPP if the consultant has not been providing ongoing management of the patient for this condition after his/her initial consultation.
Levels of E/M Services
One of my greatest concerns regarding Mohs surgeons billing for consultation services is not the fact that they bill consultations, it is the high levels of care that are often billed.
Let’s make some basic assumptions here so that the basis for my concerns is understood.
1. A provider, who is not a Mohs surgeon, refers a patient to the Mohs surgeon for evaluation of a recurrent lesion — let’s say for a skin cancer in an area where the loss of normal tissue must be minimized, or one that has ill-defined borders. A host of other medical necessity reasons exist, but these two seem to be the most common.
2. In most cases, the Mohs surgeon will treat the patient on the same date of service that the consultation is performed. Therefore, in most cases the Mohs surgeon’s office schedules enough time to perform the surgical service.
3. The Mohs surgeon has some basic knowledge of why the patient is being referred. The Mohs surgeon is expected to evaluate a specific lesion(s), determine the appropriateness of performing Mohs based on the size, location and nature of the lesion(s), and then, in most cases, proceed to remove the lesion(s) using the Mohs micrographic technique.
So here is my concern. Why are so many Mohs surgeons billing consultations with level two and three codes (e.g., 99242 and 99243)?
What Is Required for a Level-Two Consultation (CPT Code 99242)?
1. History Components
a. one to three HPI factors (history of present illness)
b. one review of systems (ROS) related to the chief complaint.
2. Examination Components
Examination of six or more body areas.
3. Medical Decision-Making (MDM)
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
What Is Required for a Level-Three Consultation (CPT Code 99243)?
1. History Components
a. four or more HPI factors
b. two to nine ROS related to the chief complaint
c. one to three PFSH (past, family or social history).
2. Examination Components
Examination of 12 or more body areas.
3. Medical Decision-Making
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
Justifying Medical Necessity
Based on the above information, you now should start to see the problem. What is the justification for examining six or twelve body areas when the patient is being referred to you, the specialist, for evaluation of a specific problem for which you most likely will do surgery? Is it medically necessary to do a full-body exam when the only reason the patient is being referred to you is for the removal of a single lesion on the nose? (I realize that sometimes there is more than one site; but rarely six!)
Obviously, the physician will have to perform a preoperative history and examine the site(s), but extended or comprehensive body checks are inappropriate; especially when the majority of the cases are being sent by other dermatologists (many within their own practices) many of who discovered the skin cancer when performing full-body examination. Most carriers would consider this duplication of effort medically unnecessary.
E/M visits continue to be the target of many focused audits. Dermatologists and Mohs surgeons alike will need to carefully monitor the levels of care billed for their consultation service.
Below are the statistics for dermatology utilization of consultations based on CMS data for 2005:
CPT code 99241 12.16%
CPT code 99242 49.83%
CPT code 99243 34.81%
CPT code 99244 2.94%
CPT code 99245 0.26%.
More and more practices are adding Mohs surgeons or incorporating this vital surgical option to the list of services offered. As such, the need to understand all aspects of coding Mohs and Mohs-related services is important, if not critical. Not only could miscoding result in the loss of significant revenue, as Mohs is extremely profitable, incorrect coding could also trigger audits as these services are highly monitored.
In this article, we will concentrate on the consultation visits billed in conjunction with a Mohs procedure and what your practice should know about billing these types of evaluation and management services.
Some Basics
1. The intent of a consultation service is that a physician or qualified non-physician provider (NPP), or other appropriate source, is asking another physician or qualified NPP for advice, opinion, recommendation, suggestion, direction, or counsel in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.
2. Carriers will pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consultant physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.
A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice.
3. NPPs may request a consultation from a provider or an appropriate source. The consultant may be in another practice or part of his/her group. The NPP may bill a consultation if all the criteria for a consultation are met.
4. The documentation requirements for NPPs are the same as the requirements for physicians. In order to justify the billing of a consultation, the following criteria must be met.
a. The consultation service must have a written request from the requesting provider.
A consultation request may be verbal; however, the verbal interaction identifying the request and reason for a consult must be documented in the patient’s medical record by the NPP or physician who requested the consult and also by the consultant physician or qualified NPP in the patient’s medical record.
b. The consultation evaluation service must be performed.
c. A written report to the referring provider must be in the medical record.
5. NPPs must meet the collaboration and physician supervision requirements as required per state law and carrier requirements. A physician assistant must meet the general physician supervision requirement.
6. Physicians and qualified NPPs may not bill a consultation service as a split/shared evaluation and management service.
7. In an office or outpatient setting, another consultation may be requested of the same consultant NPP if the consultant has not been providing ongoing management of the patient for this condition after his/her initial consultation.
Levels of E/M Services
One of my greatest concerns regarding Mohs surgeons billing for consultation services is not the fact that they bill consultations, it is the high levels of care that are often billed.
Let’s make some basic assumptions here so that the basis for my concerns is understood.
1. A provider, who is not a Mohs surgeon, refers a patient to the Mohs surgeon for evaluation of a recurrent lesion — let’s say for a skin cancer in an area where the loss of normal tissue must be minimized, or one that has ill-defined borders. A host of other medical necessity reasons exist, but these two seem to be the most common.
2. In most cases, the Mohs surgeon will treat the patient on the same date of service that the consultation is performed. Therefore, in most cases the Mohs surgeon’s office schedules enough time to perform the surgical service.
3. The Mohs surgeon has some basic knowledge of why the patient is being referred. The Mohs surgeon is expected to evaluate a specific lesion(s), determine the appropriateness of performing Mohs based on the size, location and nature of the lesion(s), and then, in most cases, proceed to remove the lesion(s) using the Mohs micrographic technique.
So here is my concern. Why are so many Mohs surgeons billing consultations with level two and three codes (e.g., 99242 and 99243)?
What Is Required for a Level-Two Consultation (CPT Code 99242)?
1. History Components
a. one to three HPI factors (history of present illness)
b. one review of systems (ROS) related to the chief complaint.
2. Examination Components
Examination of six or more body areas.
3. Medical Decision-Making (MDM)
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
What Is Required for a Level-Three Consultation (CPT Code 99243)?
1. History Components
a. four or more HPI factors
b. two to nine ROS related to the chief complaint
c. one to three PFSH (past, family or social history).
2. Examination Components
Examination of 12 or more body areas.
3. Medical Decision-Making
a. low risk
b. limited number diagnoses or management options
c. limited amount of data to be reviewed.
Justifying Medical Necessity
Based on the above information, you now should start to see the problem. What is the justification for examining six or twelve body areas when the patient is being referred to you, the specialist, for evaluation of a specific problem for which you most likely will do surgery? Is it medically necessary to do a full-body exam when the only reason the patient is being referred to you is for the removal of a single lesion on the nose? (I realize that sometimes there is more than one site; but rarely six!)
Obviously, the physician will have to perform a preoperative history and examine the site(s), but extended or comprehensive body checks are inappropriate; especially when the majority of the cases are being sent by other dermatologists (many within their own practices) many of who discovered the skin cancer when performing full-body examination. Most carriers would consider this duplication of effort medically unnecessary.
E/M visits continue to be the target of many focused audits. Dermatologists and Mohs surgeons alike will need to carefully monitor the levels of care billed for their consultation service.
Below are the statistics for dermatology utilization of consultations based on CMS data for 2005:
CPT code 99241 12.16%
CPT code 99242 49.83%
CPT code 99243 34.81%
CPT code 99244 2.94%
CPT code 99245 0.26%.
