# Re: Consultation Requirements



## medicalsec (Apr 7, 2009)

*Re: Consultation Requirements*

We are a surgeon's office, and we are trying to get the referring doctors to indicate if they are sending the patient to us for a consultation so that we can be compliant with Medicare's billing policy. We send them a form asking them what is the intent of their patients visit. If they do not use the word consultation and use the wording Evaluate and Treat, does the word evaluate substaniate a consultation request? I am finding that most of the referring offices do not really understand the meaning of a consultation, and they just don't understand why we are trying to determine the intent of the visit. They say of course it is a consultation, but we have nothing in writing to prove that it is really a consultation!!

Thanks,

Dee


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## LLovett (Apr 7, 2009)

Can you get copies of the requesting doctors medical record? It should indicate whether it is a transfer of care or a true consultation.

Just a thought,

Laura, CPC


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## RebeccaWoodward* (Apr 7, 2009)

F. Documentation for Consultation Services 

*Consultation Request*

A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record, indicating a request for a consultation service was made by the *requesting physician *or qualified NPP.

The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient's medical record and included in the requesting physician or qualified NPP's plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.

I agree with Laura...this is another route to ensure proper documentation.  

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.10


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## medicalsec (Apr 7, 2009)

We started to send the referring Doctor's office a form because we have had problems getting notes, reports, etc. It has been a big problem in our area.

The doctor's offices that we have called often tell us that  it is a consultation, but it is often times not documented in the referring doctor's notes even when they send them to us. Many do not use the word consultation, but they say to evaluate and treat, and that is why I was wondering if the word evaluate would substantiate a consultation because it would seem that the final decision was not made regarding treatment? I have tried to explain the difference between transfer of care and a consultation to many of the offices, and I am amazed that they don't seem to understand what I am talking about.

Thanks for your response!

Dee


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## LLovett (Apr 7, 2009)

It sounds like your doctors are going to have to cover themselves the best they can. A consult is based on intent. Many visits to specialists, like surgeons are not truly consults, they are just transfers of care.  

Unfortunately in lay terms consultation is used to indicate a first time visit so that is where the disconnect is most likely coming from. When the intent is questionable my advice would be go with the new patient code instead of a consult to be safe. I would rather get a little less and know I can support it than go for higher reimbursement and have to pay it back plus interest.

Just my opinion,

Laura, CPC


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## pamtienter (Apr 7, 2009)

As Laura states, a consult is based on intent. I wouldn't say that "evaluate" means "consult". You'll need to find out what the requesting provider is actually looking for. Unfortunately, this isn't always easy. Is the patient being sent to the surgeon for a problem that the referring physician knows the surgeon will take care of? Then it's a transfer of care. Is it a problem that the referring physician wants the surgeon to see the patient for and relay his advice as to whether surgery is needed or not? Then it might be a consult.  Remember, the physician sending the patient to the surgeon needs to be requesting the surgeons opinion and/or advice. 

We have surgeons who say EVERY patient that is referred to them is a consult because they are specialists, therefore their opinion is warranted. Their opinion might be warranted but that doesn't mean it's a consult. If it is known that the patient has gallstones, for example, and the Family Practitioner sends them to a surgeon to get them removed, it isn't a consult. The request to the surgeon then might be "evaluate and treat".  

Check out the link Rebecca sent starting on page 52. Good info. Good luck!


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## RebeccaWoodward* (Apr 8, 2009)

Well said Pam.  I do agree that not every visit to a sugeon is a consult; *however*, as you mentioned, there are situations when the sugeons advice is being sought.  Neurosugery, as an example, is a very complex specialty.  There are times when internal med/family practice physicians aren't quite sure on what the next form of treatment should be.  Yes...the internal med/family practice physician may determine that the patient has a herniated disc but more often than not...there are many other underlying issues.  The specialist is better equipped to make a final assessment and determine what the next course of treatment should be...pain mgmt versus sugery.


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## Barbara Burgess (Apr 9, 2009)

This is a battle I deal with several times a week.  I have some docs who insist that they ONLY see consults.  I have some that, to me, the documentation supports a consult and the doctor disagrees and says it's not.  A provider I recently met with had an interesting twist on the idea of faxing a form to the requesting provider to clarify thier intent and fax back to the specialist as Dee mentioned in her post.  This doc (a neurologist) however, believes that all new patients he sees are consults. New patients are not permitted call his office to schedule a clinic appointment; all appointments must be scheduled by the referring clinic staff.   His form that he faxes to the requesting provider does not require an answer back.  It basically _informs_ the doc (usually the PCP) that they have "requested a consult" and that he, "as a consultant", will  1) See the patient for one or two visits. 2) Render his advice on how best to manage the patient.  3) Submit a comprhensive report of findings and suggestions and 4)Be available to answer furthur questions.  

The form then goes on to instruct that when the PCP sees the patient again for the problem, if they believe a transfer of care is indicated, to please contact his office to arrange this. It also instructs at the bottom of the form "Please retain this letter in your patients chart. This procedure ensures compliance with certain billing and documentation requirements for consultations issued by the Center for Medicare and Medicaid." 

I thought it was interesting, I'm just not sure if it will fly in every situation. (or at all) One chart that I recently reviewed was a patient who had previously been under the care of a neurologist for migraine headaches and had recently relocated to our area.  Upon establishing herself with a primary care doc, she also requested a written referral (a requirement of her particular insurance) to a neurologist.  The primary docs note clearly was NOT asking for an opinion or advice, but simply stated that *as per the patient's request*, they would refer to neuro.  To me, that still would NOT be a consult but the neuro doc apparantly feels that he can bill a consult based on his fax being sent to the PCP.

*Not everything that counts can be counted, and not everything that can be counted counts" ~ Albert Einstein*


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## RebeccaWoodward* (Apr 9, 2009)

Barbara,

This is troubling.  I just hope that one of the referring physicians doesn't decide to contact Medicare. Your physicians fax does not warrant or justify a consult; as you have already stated. It boils down to the intent of the PCP's reqest.  I know, at times, there can be some gray areas but your last scenario seems pretty clear; especially since the PCP states he is not seeking an opinion. Have you expressed your concerns to your administration?


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## Barbara Burgess (Apr 9, 2009)

I guess I should have clarified that he is not _currently_ using the form in his practice.  It was something he brought in from his previous practice and is proposing its use in his clinic here.  It is currently under review in our compliance department.  

While I can see where it may hold up for a legit consult and/or at least give the referring provider an opportunity to clarify in the absence of a written referral/consult request, I definitely have my qualms about using it in it's current format.   I think that, for his specialty, a good number of patients truly are consults, but I don't see that every patient who comes in his door with a chief complaints of "headaches" warrents a consult.  Yes, he has to work them up and determine the actual diagnosis and propose treatment or management, but having also worked in primary care in the past I know that a lot of the time the PCP's true intent in sending them to neuro is, "I don't want to fool with managing this so here....... you take it".  On the other hand, it may be a problem patient with chronic daily headaches that the neurologist doesn't want to keep either, so his advice may very well be "This is what your patient has and this is what I suggest YOU do with them" and then send them right back to the PCP after a couple of visits.  In that case, the PCP's intent was to refer and transfer care but what they actually wound up with  was the consultant's advice and opinion.  That is where the neurologist feels justified in saying that he renders a consult to all new patients, and _then_ the PCP can determine if transfer of care is appropriate and desired. I can see both sides of the argument (clear as mud !); some days I'm not sure if I should be working for the physician or the payers !! 

*Not everything that counts can be counted, and not everything that can be counted counts" ~ Albert Einstein *


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## FTessaBartels (Apr 9, 2009)

*PCPs don't understand*

Barbara,
Verrrry interesting ...
I'm wondering how many PCPs start referring patients to a different neurologist. 

PCPs really don't understand consultations because they don't use the code and there's no financial ramification for them when the code is misused. In that sense, I kind of like your neurologist's approach - he only takes new patients with a direct contact from the PCP's office calling for the initial appointment and he faxes back a specific form about consultation. 

I think it would be better if he had a choice for the PCP to checkmark and return ... so you could have his current statement (maybe modified a bit) as choice #1, and a different statement about "request to treat a problem needing neurologist's expertise."  

One dermatologist I know has nothing half so detailed as what your neurologist has, but does fax back to the PCP a request/referal form with something along the lines of:
REQUEST FOR CONSULTATION (evaluation of issue and report back to PCP with recommendations)
    nature of problem:

REFERRAL FOR TREATMENT (diagnosed problem requires expertise of dermatologist for treatment)
   nature of problem:

Once she gets the form back she sets the patient appointment. 

I particularly like how she combines Request with consultation, and referral with treatment. In her own little way she's trying to educate the PCPs one doctor at a time. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Cindy711 (Apr 10, 2009)

OMG!  I have these same problems.  I constantly have try and explain the difference between a consut ansd a referral to my staff.  Some people just don't get it.  Here is a question I would appreciate some feedback on.  Coders in our office are disagreeing about this.  If the DR uses a consult code say, 99244, and we know it was not a consult but a new patient we change it.  One coder believes you just cross over to a 99204.  Others say you have to go up a level.  Advice?


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## renifejn (Apr 10, 2009)

The documentation requirements (meaning numebr of elements needed) are the same for new patient/consult so it should just be able to go from 244 to 204 or vice versa.


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