Hi Eastland Dental Center!
Great questions. Yes 99242 can be used when a patient is directly referred from another healthcare professional. Using this group of Evaluation & Management (E&M) codes, known as "consultation" E&M codes, 99241-99245 does require the direct referral as well as a letter back to the referring health professional. However, Medicare stopped accepting these codes back in 2010, so some private insurers no longer accept them either.
In general, the "consultation" E&M coding set 99241-99245 does have a bit higher allowed amounts than the "new patient" E&M coding set 99201-99205.
When it comes to the documentation requirements vs. time spent for E&M coding, most practices go by documentation requirements, which for each level of code (1-5) requires a certain level of history taken from the patient, a certain level of exam performed by the doctor, and a certain level of medical decision making.
If you are using time spent as the key factor for selecting the level of E&M code, yes you always want to make sure that you record the amount of time the patient spent face to face between the patient & doctor, and that at least 50% of that time was spent counseling the patient (and also important to note what was discussed during the time spent counseling).
Here is the break-down of the required documentation for the different levels & types of visits:
New Patient Codes (not referred)
99201
• 10 min face to face w/ doc - Presenting problems are self-limited or minor
Or
• A problem focused history
• A problem focused exam
• Straightforward medical decision making
99202
• 20 min face to face w/ doc – Presenting problems are low to moderate severity
Or
• An expanded problem focused history
• An expanded problem focused exam
• Straight forward medical decision making
99203
• 30 min face to face w/ doc – Presenting problems are moderate severity
Or
• A detailed history
• A detailed exam
• Low complexity medical decision making
99204
• 45 min face to face w/ doc - Presenting problems are moderate to high severity
Or
• A comprehensive history
• A comprehensive exam
• Moderate complexity medical decision making
99205
• 60 min face to face w/ doc 0 Presenting problems are moderate to high severity
Or
• A comprehensive history
• A comprehensive exam
• High complexity medical decision making
Established Patient Codes:
99211
• Visit may not require presence of doc, typically 5 min spent with patient
Or
• Do your SOAP notes!
99212
• 10 min face to face w/ doc - Presenting problems are self-limited to minor
Or
• A problem focused history
• A problem focused exam
• Straightforward medical decision making
99213
• 15 min face to face w/ doc - Presenting problems are low to moderate severity
Or
• An expanded problem focused history
• An expanded problem focused exam
• Low complexity medical decision making
99214
• 25 min face to face w/ doc - Presenting problems are moderate to high severity
Or
• A detailed history
• A detailed exam
• Moderate complexity medical decision making
99215
• 40 min face to face w/ doc - Presenting problems are moderate to high severity
Or
• A comprehensive history
• A comprehensive exam
• High complexity medical decision making
Consultation Codes (patient’s referred directly from other health providers)
Special note on this set of E&M codes:
• requires follow up letter to referring health professional
• some companies no longer accept these codes, only new & established codes
99241
• 15 min face to face w/ doc - Presenting problems are self-limited or minor.
Or
• A problem focused history
• A problem focused exam
• Straightforward medical decision making
99242
• 30 min face to face w/ doc - Presenting problems are low severity
Or
• An expanded problem focused history
• An expanded problem focused exam
• Straightforward medical decision making
99243
• 40 min face to face w/ doc - Presenting problems are moderate severity
Or
• A detailed history
• A detailed exam
• Low complexity medical decision making
99244
• 60 min face to face w/ doc - Presenting problems are moderate to high severity
Or
• A comprehensive history
• A comprehensive exam
• Moderate complexity medical decision making
99245
• 80 min face to face w/ doc - Presenting problems are moderate to high severity
Or
• A comprehensive history
• A comprehensive exam
• High complexity medical decision making
To learn more about E&M coding in medical billing, watch our recorded Tuesday evening study group over E&M coding! You can follow the link below, or visit the DentalWriter Help Center to watch the recording at any time!
http://www.screencast.com/users/DentalWriterStarter/folders/Study%20Group%20Recorded%20Session/media/2f53bbe2-bb2e-478b-921a-a019ee99eee5 Hope this helps, have a great day!