# Consultation Article Coding Edge



## medicalsec (May 6, 2009)

I was confused by the latest May article on Consultations in the Coding Edge.  On Page 21 it says, " The report is not a thank you, nor is it a courtesy copy of the history and physical. Rather, the report provides instruction to allow the requesting physician to continue treating the patient". We often have a written request for a consultation from our referring doctor. They are asking the opinion of our doctor, but it seems the article is saying that if it ends up to be a problem that the referring doctor can't treat that it voids the request for our opinion. I have read literally "hundreds" of articles on consultations, and I always seem to get a different spin on the situation in every article. We do bill a consultation if we have a written request for the doctors opinion even if we are the ones that continue to treat the patient for the condition. It would seem logical that if the referring doctor wants to hear back from our doctors with their opinion that it would still constitute a consultation. We are surgeons. The referring doctor may have no intention of doing surgery when they send the patient to us, but they are asking our doctors if they feel that surgery is indicated for the symptoms that the patient is having. The information in the article under the heading "Intentions Matter" seem to indicate that it would void the consultation request. We do not bill a consultation unless the word consultation or opinion is in the request. Any thoughts?

Thanks,

Debbie


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## medicalsec (May 6, 2009)

I would also like to add that I have spent hours agonizing over how to resolve this problem. We actually have a form that we send to all referring doctors offices. We have them check off on the form if they are requesting a transfer of care or a consultation, and we keep that paperwork in our chart, and we request that they do the same on a statement that is on the form. Many referring offices in our area have no clue about documentation requirements. They say of course we are sending the patient for a consultation. When we started to send out the form, doctors were calling me asking me what I was talking about. I am finding that many doctors have no idea about documentation requirements.

I have read that approximately 75 percent of consultations billed do not meet the requirements. You would think that Medicare would have the common sense to establish a policy that would save them millions/billions of dollars. If they would require a form be sent to all referring offices with the required information they would save money and clarify this "double-talk issue". We  can't read minds! We can't second guess the intent of any doctor that is referring a patient to us. I can't say that I have ever read one article that has clarified this confusing issue. Most articles just add more confusion and create more uncertainty as to how to handle this issue.

In my mind, I would think that as long as the referring doctor wants an opinion and states it by using the word consultation or the word opinion in writing that it would be considered a consultation. 

For some reason, it seems to be more accepted when patients are in a hospital setting. Multiple doctors call their visits a consultation, and yet they don't rescind their consultation status and consider it a transfer of care because the primary doctor or the original referring doctor can't treat the patient, so why does this seem to be where many of these articles are heading when they discuss office consultation patients and when the transfer of care takes place.

I would think that a consultation is a consultation (office or hospital). 

Shouldn't the critieria be the request for the opinion/consult rather than whether the problem ends up being transferred to the consultant after the visit. If you send your written reply after the first visit  then I would think that the transfer of care would have not yet taken place because you are giving your opinion regarding what you think the course of treatment should include.  Even if you end  up doing surgery or whatever, you have not performed it at that moment so I think that a transfer of care would not take place until after you have fulfilled the consultation requirements on that initial visit. This entire issue of when the transfer of care takes place and rescinding the consultation status is also very confusing. Much double-talk!!

I would appreciate any additional thoughts on this confusing issue.

Thanks,

Debbie


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## FTessaBartels (May 7, 2009)

*I don't read it the same way.*

Debbie writes: We often have a written request for a consultation from our referring doctor. They are asking the opinion of our doctor, but it seems the article is saying that if it ends up to be a problem that the referring doctor can't treat that it voids the request for our opinion.

I don't read the article that way. I think you are correct in verifying the intent of the requesting physician - is s/he asking for your opinion on the issue, or does he *already know *the patient needs surgery and is asking you to take care of it. 

The article does go on to say that the consulting physician may order additional diagnostic tests, or institute treatment. (In fact on page 22 there's an example of a consultant who begins treatment and it's still a consult.)   That does NOT negate the originating physician's *intention to seek an opinion*. 

As an example, our surgeons are frequently asked to "consult" about suspected hernias. Sometimes the surgeon evaluates the child and decides that no surgical intervention is necessary. Sometimes on evaluation the surgeon feels that surgery would be beneficial, but it's not immediately necessary. Sometimes it's clear that surgery is warranted sooner rather than later.  I tell the doctors, if "even a civilian" could tell that this condition needs surgery, the new patient (or established) visit code is probably more appropriate. But if the condition requires an *expert's evaluation and opinion to determine appropriate treatment *then it's probably a consultation. 

I do think that many surgeons use the consultation codes for all "referrals" and that's *not* appropriate.  

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## cpccoder2008 (May 8, 2009)

We were recently told by an outside auditor that if the consulting doctors does not send back a report of the finding then you cannot bill a consult because not all guidelines were meet ? Is this true ? I am familiar with the three R's so i would agree.


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## FTessaBartels (May 8, 2009)

*Report is necessary, not sufficient*

Yes, it's correct that you MUST have a written report to the requesting physician to have a consultation (this can be the shared medical record for inpatient or same practice, different specialty consults).

However, a written report is not, *by itself*, sufficient to code a consultation. Our practice sends a written "clinic letter" to the PMD of every patient for every visit ... this include post op follow-up visits. So sending a report is necessary but not sufficient to code a consult. 

F Tessa Bartels, CPC, CEMC


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## twosmek (May 13, 2009)

*Specialty Consult coding*

My office is in an uproar as well, We are an orthopedic specialty clinic. Most if not all of our new pt are referral from a PCP in our hospital system. We have the request for a referral/consult depending on the MD whether it is in the visit dictated note or in an official request. The ortho MD does send a copy of thier visit to the referring MN and most time assumes the care of that problem. I am also now asking what the intent is from the PCP and get Eval & treat almost everytime. I will list some scenerios and please help me decided which ones should be consults and which ones New pt/est pt.

#1 PCP sees pt for annual physical, pt states that they have had knee pain for 2 yrs. PCP tells the pt that they should be seen by orthopedics and sets up the appt. The pt is seen here xrays are ordered and viewed. Orthopedic MD decides that a MRI is needed and schedules the MRI and an appt for the pt to come back to review the result. A copy of the dictated note is CCed to the PCP.
Consult or New/Est Pt

#2 PCP has been seeing pt for shoulder pain for 6 months has had MRI and xrays taken. PCP decides that there is nothing more he can do and tells pt to see an orthopedic MD. Sends a request to orthopedics to schedule an appt. Pt is seen and it is determined that she needs an arthroscopy, surgery is scheduled and pt will f/u with orthopedic MD. Orthopedic CC's PCP on note.
Consult or New/Est Pt

#3 PCP decided that pt needs a steroid injection into a shoulder joint. PCP sends referal to orthopedic MD for injection. Orthopedic MD has xrays taken and then does an injection and tells pt to follow up in 2 weeks with orthopedics. Orthopedic MD sends copy of note to PCP.
Consult or New/Est Pt

#4 PCP sees pt for shoulder pain, has already had xrays and MRI ordered by PCP. PCP determines the PT needs a rotator cuff repair, tells pt he needs to have an orthopedic MD do the surgery. PCP sends referral to Orthopedic to evaluate for rotator cuff repair. Orthopedic MD sees patient and does schedule Rotator cuff repair and pt will follow up with Orthopedic MN. CCs note to PCP.
Consult or New/Est PT.

Thoughts??


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## mb12345 (May 19, 2009)

hi everbody

We are also having issues with determining if it is a consult or not.  Our questions mainly come from the inpatient side.  

Here is our scenario:

Patient is admitted to the hospital for gastroenteritis and is also an insulin dependent diabetic.  The insulin levels are all over the place and the attending physician calls in the patient's endocrinogist to review and order plan of care to correct the insulin levels.  This physician already sees the patient on a regular basis for the diabetes.  Would you consider this a consultation or subsequent care?  Our MD's are calling it a consult b/c they give the plan to the attending to implement.  We only allow one MD to do orders on inpatient basis.

Any help or thoughts would be greatly appreciated!

Thanks
MaryBeth


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## Karolina (May 19, 2009)

*To MaryBeth's question*

It looks like your endocrinologists have been seeing the patient for the diabetes for a while and treating him/her over time. The endocrinologist now comes in to see the patient as asked by the attending to review and order the plan of care. This wording sounds very much like the endocrinologist makes the decision on how to deal with the diabetes, even if the attending executes the plan. This visit is more for management than advice regarding the diabetes and so I would use the subsequent care code. 
Also, would it be ethical to bill a consult, after knowing the patient so well? But that's a whole new discussion.


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## Barbara Burgess (May 20, 2009)

The fact that the endocrinologist already knows the patient has nothing to do with a consult.  There are no "new patient" and "established patient" consults.  As for the described scenario, it's a little tricky because of the ordering policy at that hospital.  Obviously, the GI doc is having problems with and/or is not comfortable managing the diabetes and blood sugar without some help from the Endo.  Where I work, it would clearly NOT be a consult, because the Endo would take over managing the DM and BS from that point on.  In this case however, it appears to me that the GI doc IS asking for the "advice or opinion" of the Endo doc in order for the GI doc to continue managing the treatment the patient.  Since it is inpatient, it is a shared chart so as long as there is an order or request for consult and a consult report that includes history, exam and MDM, then I would count it as a consult.  Back when we still had the old follow up consult codes in place, whether or not the consultant was writing treatment orders in the chart was one of the things we looked for.  If he had done the initial consult and then started writing treatment orders (as opposed to orders for diagnostic workup) rather than just making suggesting or recommendations to the attending, he would now be taking care of the patient for whatever the problem was that he was consulted for........... i.e. "transfer of care".

As for the ortho scenarios, I would say that #1 is a consult, #2 is iffy, #3 & #4 are not.


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