By Steve Verno Quality Medical Management/Emergency Medicine Specialists |
The Second Opinion


The Second Opinion

Date Posted: Tuesday, September 27, 2022


In the 1960s, I was 13 years old and started having eye problems.  My parents were approved to receive Medicaid, so my parents took me to the local mall and had an eye doctor examine me, and the eye doctor said I needed to wear glasses.  Every couple of years, I had to go back to see an eye doctor to have my eyeglasses updated. Now, most insurance companies do not pay for eyeglasses. Medicare especially is very strict on this.  
Recently, I went to my Walmart optical center for a routine eye exam to get new eyeglasses.  Typically, the eye exam would take me about an hour, and when I was done, I paid the $400 for the exam, and soon afterward, I would get a new pair of glasses at a cost of approximately $600.  At this last visit, the eye doctor found something wrong and referred me to an eye specialist. The Walmart eye doctor sent me for a second opinion to find out why my vision was getting worse.  The second opinion was a covered service by both my primary and secondary insurance.  

This visit was the first step of the second opinion.  The first step is simple:  There must be a request by a doctor and the request must be done in writing.  I went to a local eye specialist who did another test; in his office, he told me that I have cataracts in both eyes.  While a routine eye exam for glasses is not covered by insurance, cataract surgery is covered.  At the visit, the surgeon asked me if I wanted up-close vision to read with (nearsightedness) or if I wanted far-away vision (farsightedness).  Contrary to the movie, Trading Places, I couldn't have both.  I chose far-away vision.  I went in for the surgery, which lasted about an hour, and then came back another day to have the other eye done.  

This surgery was the second step of the second opinion, which is called rendering or providing the care recommended by the original physician-in my case, this was the surgery itself.  After 50 years of wearing glasses, I now only need to use reading glasses, though according to my new prescription, they can be obtained at my local Dollar Tree for $1.25.  That's astonishingly less than the $400 for the eye exam and $600 for glasses that I used to pay.  I am frugal, but prepared. I bought six pairs of glasses to be used for emergencies.

The eye surgeon performed the last step of the second opinion, and this was a report.  He sent a detailed report of the exam and surgery, in writing, to the Walmart eye doctor and to my primary care provider.  These three steps are the requirements for what is called a consultation or a consult.  
According to the U.S. Department of Health and Human Services, Office of Inspector General Report, March 2006, $3 Billion was billed by physicians for consultations.  77% did not meet the requirement for a consultation.  As patients, both my wife and I were seen by doctors who billed us for a high level of consultation. None of them met the requirement for a consultation.  

A consultation requires the following:  
  • A chief complaint
  • A documentation of a history
  • A documentation of a medical examination
  • A documentation of a medical decision making

There are five (5) levels of consultations.  The CPT levels for a doctor's office are 99241, 99242, 99243, 99244, and 99245. Inpatient consultation codes are 99251, 99252, 99253, 99254, and 99255.

Just after I had my open-heart surgery in 2007, I started experiencing chest pain, so I went to see my doctor; he did a simple EKG and sent me to see a cardiologist in the same medical plaza.  After many tests were done, the cardiologist put me on blood thinners as my pain was caused by a thickening of my blood.  Once a week, I went to see the cardiologist's blood thinner nurse, who, with the cardiologist, made changes to my medication.  

The cardiologist followed the consultation rules.  He received a request from my primary care provider, rendered the medical care for blood thinners, and sent a detailed report back to my primary care provider as to how he wants my heart care to continue.  He recommended I return to see him to regulate my blood thinner medication.  The moment that the cardiologist took over the care for the regulation of my medication, his visit was no longer a consultation.  When a doctor takes over the care from another doctor, that visit becomes a simple outpatient visit.  The level of the visits is determined by the Evaluation and Management Guidelines.  Medical specialties often use them for consultation services, which basically is their bread and butter.  

Back in 2010, almost every insurance company, more so than Medicare, stopped paying for a consultation.  The reason is simple: upcoding.  A patient would seek care from a specialist, and when the bill came in the mail, the patient was billed for a 99245 consult, the highest level of consultation that can be billed.  When a patient complained and asked to see the medical records, the request was denied, so the patient would contact the Office for Civil Rights (OCR) and the state health department, where the medical record copy would finally be provided.  So, because specialists and other doctors cannot receive payment for a consultation, what can they do?  

On December 18, 2009, in CMS Publication 100-02, physicians and practitioners are instructed to bill a new or established patient visit CPT code (in the range of CPT codes 99201-99215).  

Here is what Medicare pays a participating provider for a routine office visit in the State of Florida:
99201:  $45.70 99211:  $22.65
99202:  $73.05 99212:  $56.62
99203:  $113.20 99213:  $90.90
99204:  $168.83 99214:  $127.97
99205:  $223.45 99215:  $181.42

What will happen to a doctor who decides to upcode a patient visit as a means of increasing practice revenue?  The answer is simple: The patient will seek medical care elsewhere.  There is an old Klingon proverb: Doctors are not an endangered species; doctors who upcode a patient visit will become an endangered species.  

So, what happened when the doctor who billed us for a 99245 consultation learned he wouldn't be paid for a consultation? He decided to bill us for a 99215 office visit.  The moment he did this, we terminated our patient-provider relationship.  He is currently posting billboards along the highway, putting advertisements in the local penny saver magazine, and he goes to the senior citizen apartment complexes, where he tells all of the residents that if they make an appointment for their first visit, he will not bill Medicare and will give them free medical care.  He might need a second opinion.     

Steve Verno, CMBSI, CHCSI, CEMCS, CMSCS, CPM, CHM is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University.

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Steve Verno

Medical Billing and Coding Instructor/Consultant
Quality Medical Management/Emergency Medicine Specialists

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