Second Opinion - To Bill, or not to Bill a Consultation
Effective January 1, 2006, the Confirmatory Consultation codes 99271-99275 were deleted. Therefore, second opinions can no longer be billed as confirmatory consultations.
A consultation service is distinguished from other evaluation and management (E/M) visits in that it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. All requirements for consultation services must be met, as defined in the Internet Only Manual (IOM): Pub 100-4; Ch. 12, §30.6.10.
For Medicare purposes, a second opinion is different from a consultation in that the request for the opinion or advice of another physician or NPP regarding a previously recommended medical treatment or surgical procedure is initiated by the patient and/or family, or is mandated (e.g., by a third-party payer). When a second opinion is requested by the patient or family, Medicare does not require that a written report be sent to a physician. Second opinion E/M services may not be billed as consultations.
A second opinion E/M service provided to satisfy a requirement for a third party payer is not a covered service in Medicare. The CPT modifier-32 (Mandated Services) is not recognized as a payment modifier in Medicare.
A second opinion E/M service performed in an office or other outpatient setting should be reported using CPT codes 99201-99205 for a new patient, and CPT codes 99212-99215 for an established patient. The three year rule regarding "new patient" status applies.
Generally, in the inpatient hospital and Nursing Facility (NF) settings, a request by the patient and/or family for a second opinion E/M service is made through the attending physician or physician of record. In the hospital setting, when the request does not meet the consultation requirements, the E/M services are reported using the Subsequent Hospital Care codes (99231-99233). When the consultation requirements are not met in the Nursing Facility setting, report Subsequent NF Care codes (99307-99310).
Please see the Internet Only Manual (IOM), Pub 100-4; 30.6.10D: Consultation Services Codes (99241-99255), Second Opinion E & M Services Requests, for additional information.
