# Wording for consultation



## tbramhall (Jun 3, 2009)

Was wondering how other coders see the following documentation? 
These are inpatients and the requesting provider in a shared chart writes orders " Palliatvie care to consult"

The palliative care provider starts the report with:

" Palliative care consultation was requested by Dr XXXXX for management of pain for (a specific problerm.)"
Then the provider documents the HPI, ROS, PSFH, Exam and Impression, but instead of plan, the section's title is RECOMMENDATIONS.

Then in sharded chart will written order for medication.

I am from Nebraska, so WPS is our Medicare carrier and they are different from what we had before.  So some of us is still wondering about the word "management, was being transfer of care or not.

Thank for any thoughts.


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## LLovett (Jun 3, 2009)

My opinion is your documentation appears to support a consult. It doesn't look to me like the requesting provider is handing the care over, they just want options. I haven't read anything from WPS that states if you use the word "management" it disqualifies your visit as a consult.


http://www.wpsmedicare.com/part_b/education/em_qa.pdf

There are a couple links to in this document to the policies that govern consults.

Laura, CPC


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## tbramhall (Jun 3, 2009)

Thanks for you help Laura. 
We are getting requestes for documentation from WPS on our consults reports, only finding out the way some provider word the intent is wrong.  This provider tries so hard to do things right, want to help her out.


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## FTessaBartels (Jun 3, 2009)

*"Tweeking" the wording*

I agree with Laura, that your original wording seems to support a consultation. 

But if your doctor is concerned, perhaps the following wording might accurately describe the encounter: "Palliative care consultation was requested by Dr XXXXX for advice on pain management options for (a specific problerm.)"

Hope that helps

F Tessa Bartels, CPC, CEMC


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## mmunoz21 (Jun 4, 2009)

The wording to me sometime can get you in troubel, I work for a payer and I audit E&M records on a daily basis....  

I copy and pasted these from WPS....

A Consultation: The intent of a consultation service is that a physician or qualified NPP or other appropriate
source is asking another physician or qualified NPP for advice, opinion, a recommendation,
suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual
has expertise in a specific medical area beyond the requesting professional's knowledge.
Consultations may be billed based on time if the counseling/coordination of care constitutes more
than 50 percent of the face-to-face encounter between the physician or qualified NPP and the
patient. The preceding requirements (request, evaluation (or counseling/coordination) and
written report) shall also be met when the consultation is based on time for
counseling/coordination.

So the Dr. sending the patient to another Dr. is requesting an "Opinion/Advice/Recommendation..... the referring Dr. will continue to treat the patient for the condition based on the recommendations made by the specialist...

Transfer of Care:: When this transfer is arranged, the requesting physician or qualified NPP is not asking for an
opinion or advice to personally treat this patient and is not expecting to continue treating the
patient for the condition. The receiving physician or qualified NPP shall document this transfer
of the patient's care, to his/her service, in the patient's medical record or plan of care.
In a transfer of care the receiving physician or qualified NPP would report the appropriate new
or established patient visit code according to the place of service and level of service performed and shall not report a consultation service....

Transfer of Care:: A Dr. is sending/referring this pt out to another Specialist who can and will handle the care for that particular condition...the referring Dr. is not going to be treating the pt for that specified condition....

Hope this helps....


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## tbramhall (Jun 4, 2009)

Thanks everyone who replied.  I said this before on a different thread, but AAPC has the best support team around.

Thanks again.


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