# Consult Uh OH



## KimmHall (Jul 8, 2009)

Hello my fellow Coders,
   I am posting this underneath two forums because it applies to both and I need as much feedback as I can get. 
    Yesterday I was thrown for a bit of a loop during a Medicare Webinar on consults that seemed to change what I have always been accustomed to. I am not new to coding however consults have been under quite a bit if scrutiny and I am trying to be as educated as possible so that I can educate my doctors as well.
    Here is my scenario and question:
	A patient presents to the ER with dysphagia. The ER doctor requests a GI consult. GI comes in and examines the patient (performs all the components of an E/M level). GI subsequently takes the patient to the endoscopy unit (or stays in the ER) and performs and EGD and removes a fish bone. The patient is discharged home with follow up instructions.

Question: Does GI bill a consult code? Why or why not?

PS: I know that a modifier would be needed on the E/M, and the procedural and dx coding my main focus is whether or not this is a true consult. 

Thank You in advance for sharing your thoughts and opinions with me.

Kimm Hall CPC, CGCS, CMSCS


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## Anna Weaver (Jul 9, 2009)

*consult*

I would say yes, it's a consult. My reasoning is that it was at the request of  Dr. ER, who felt a specialist should see the patient. Dr. GI examines the patient and decides at that point to do an EGD. He didn't know when he came in to see the patient that he would be doing an EGD, that decision was made at the time of the exam. So you have your request (Dr. ER), Dr. GI renders an opinion, and sends/documents a report.


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## RebeccaWoodward* (Jul 9, 2009)

I agree with Anna.  

*Consultation Followed by Treatment*

*A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service *or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.

Medicare Chpt 12 30.6.10  B


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## KimmHall (Jul 9, 2009)

I would agree with you both however I was told yesterday by the educational rep from medicare that it is _not _a consult. According t her her a consult is the request of advice or an opionion on how to treat a problem or symptom. The ER doctor is not asking for advice on how to treat the patient he is asking for the patient to be treated_(per her this is a transfer of care)._ Also she states that an ER doctor does not meet the requirements for a consult because the specialist is not giving the care back to the ER doctor to manage (essentially they have treated the problem they were called for). This was after a long discussion and review with her of that very same section (Medicare Chpt 12 30.6.10 B ) of the manual. This totally blew away what I have always thought to be accurate. Your thoughts?


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## Anna Weaver (Jul 9, 2009)

*consultation*



KimmHall said:


> I would agree with you both however I was told yesterday by the educational rep from medicare that it is _not _a consult. According t her her a consult is the request of advice or an opionion on how to treat a problem or symptom. The ER doctor is not asking for advice on how to treat the patient he is asking for the patient to be treated_(per her this is a transfer of care)._ Also she states that an ER doctor does not meet the requirements for a consult because the specialist is not giving the care back to the ER doctor to manage (essentially they have treated the problem they were called for). This was after a long discussion and review with her of that very same section (Medicare Chpt 12 30.6.10 B ) of the manual. This totally blew away what I have always thought to be accurate. Your thoughts?



My goodness. I'm afraid I don't agree with her. An emergency room DR can and does request consultations. He would be given back the treatment if the GI Dr. agreed that there would be no need of treatment by him. I have seen this happen. There are no guides I know of that say ER Dr's cannot do this. I do not agree about this being a transfer of care. DR GI didn't know until he came in what would happen. This is obviously controversial, but my opinion is that it's a consult. Until Dr. GI examines, he doesn't know what is wrong or what treatment will be rendered, if any.


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## RebeccaWoodward* (Jul 9, 2009)

Boy oh boy...this can become so gray.  I suppose this is why Medicare is considering "doing away" with consultations.  Here's my opinion.  First of all, I have never been taught that an ER physician can't request a consult nor have I ever seen this in writing.  Now...if this is a guideline exclusive to your region, that may be another story.  To start the ball rolling, I would ask for the Medicare guideline that she is citing and ask to explicitly show you where an ER physician is removed from this protocol.  I can, somewhat, understand her thinking about the "transfer of care" issue, but the GI physician can not render an opinion until he examines the patient.  It makes me wonder if this "educator" is implying that the GI physician should be the admitting physician. If the ER physician *is* asking for the GI specialist to take over the care, I could see her point; however, to say that an ER physician can NEVER request a consult, I just can't digest this.  You certainly have given me something to research today!!

Ok guys...time to chime in on this one........


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## RebeccaWoodward* (Jul 9, 2009)

Now...I want to clarify...If the ER physician is expecting the specialist to manage the care of this patient, I would agree that it would _not_ be a consult.  However, if the intent is to seek an opinion and it is properly documented, then I would have to agree that a consult is warranted.  After all, the consulting specialist doesn't always render treatment.  I was able to locate a citing from CPT Assistant...

December 2005 page 10
Coding Consultation:Questions and Answers

Evaluation and Management: Consultations (Q&A)

Question

Question: Is it appropriate to report the Initial Inpatient Consultation codes (99251-99255) when a consultation is provided in the emergency department?

AMA Comment

AMA Comment: No. As stated in the Office or Other Outpatient Consultations guidelines, "The following codes are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department [emphasis added]." Therefore, if a consultation is provided in the emergency department, the appropriate Office or Other Outpatient Consultation code (99241-99245) should be reported


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## Lisa Bledsoe (Jul 9, 2009)

Check this link out:
http://www.trailblazerhealth.com/Publications/Job Aid/consultation services job aid.pdf
I stand by my _opinion_ that this scenario is not a consult.


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## Anna Weaver (Jul 9, 2009)

*consult*

Well, this is certainly a gray area. But, I still feel this could constitute a consult, if as has been pointed out, if all the correct documentation is there. There are no rules, or guidelines that say an ER physician cannot call for a consultation (at least that I know of). I also agree there are fine lines in the documentation for these codes; consultation vs referral or transfer of care. But, I also stand by my opinion that just because an ER Dr calls in another Dr. does not necessarily mean it's a transfer of care. It can and has been put back on him (DR ER) to take care of the patient after the specialist has examined and rendered his opinion. I think, as always, this will be a case by case basis. They cannot across the board say this isn't going to happen. Unless, or until they remove the consult codes altogether or put in writing that specific specialties/areas cannot request consults. Wow, this is something to think about. Thanks guys!


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## LLovett (Jul 9, 2009)

Something else to think about.

In your situation when the specialist doesn't treat the patient and sends them back to the ER doctor, you are basing the coding of a consult on the outcome of the visit. Consults are based on intent, not outcome. Any provider can get a transfer of care and refuse to continue care after seeing the patient. That doesn't make it a consult.

Laura, CPC


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## Anna Weaver (Jul 9, 2009)

*consultation*



katmryn78 said:


> Something else to think about.
> 
> In your situation when the specialist doesn't treat the patient and sends them back to the ER doctor, you are basing the coding of a consult on the outcome of the visit. Consults are based on intent, not outcome. Any provider can get a transfer of care and refuse to continue care after seeing the patient. That doesn't make it a consult.
> 
> Laura, CPC



Well, that's true, but the consult was still there. The requirements, and documentation met, so it's still a consult. Now, if Dr. ER said, please come take care of this patient instead of saying please come see what you think, then it's a transfer and that would stand also, no matter the outcome. 
Your right, it's all about intent and I don't feel that if the documentation is there that CMS can say it's not a consultation without something to back that up. I guess all I'm saying is the clarification needs to come from higher up at this point as we will be able to argue this for awhile yet. Documentation, at this point, is the key. Intent is the guiding factor.


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## RebeccaWoodward* (Jul 9, 2009)

While this particular scenario may seem a little muddy as far as the intent, someone I greatly admire shared this with me.

There are still many cases where the ED physician is asking for an opinion, usually regarding whether the patient's presenting problem is related to a certain body system that pertains to a certain specialty. For example, chest pain can be caused by several things—respiratory distress, coronary pathology, hiatal hernia, etc., each of which is handled by a physician of a different specialty. The ED provider may not feel comfortable making the final dx, and so will make their best guess as to which one is the likeliest candidate and usually call that specialty in first to provide an opinion. Let's say the ED provider calls in Cardiology to provide an opinion as to whether or not the problem is a cardiological one. The ED provider does not KNOW that the Cardiology provider coming to the ED as a result of their request will be taking over because they don't even know yet if the patient's problem is cardiological in nature—that's the whole point of asking for the cardiological opinion/consult. Let's say in this situation that the cardiologist consultant provides the opinion that the patient's problem is NOT in fact related to any coronary pathology that they can find. At this point, the ED provider may choose to discharge the patient, order add'l tests, or consult another specialty.

So because of the fact that ED providers often request opinions from specialists in order to rule out certain conditions and to help them determine who they should call or consult next, the services they request will often be accurately billed by the requested provider as a consult.


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## Anna Weaver (Jul 10, 2009)

*consultation*



rebeccawoodward said:


> While this particular scenario may seem a little muddy as far as the intent, someone I greatly admire shared this with me.
> 
> There are still many cases where the ED physician is asking for an opinion, usually regarding whether the patient's presenting problem is related to a certain body system that pertains to a certain specialty. For example, chest pain can be caused by several things—respiratory distress, coronary pathology, hiatal hernia, etc., each of which is handled by a physician of a different specialty. The ED provider may not feel comfortable making the final dx, and so will make their best guess as to which one is the likeliest candidate and usually call that specialty in first to provide an opinion. Let's say the ED provider calls in Cardiology to provide an opinion as to whether or not the problem is a cardiological one. The ED provider does not KNOW that the Cardiology provider coming to the ED as a result of their request will be taking over because they don't even know yet if the patient's problem is cardiological in nature—that's the whole point of asking for the cardiological opinion/consult. Let's say in this situation that the cardiologist consultant provides the opinion that the patient's problem is NOT in fact related to any coronary pathology that they can find. At this point, the ED provider may choose to discharge the patient, order add'l tests, or consult another specialty.
> 
> So because of the fact that ED providers often request opinions from specialists in order to rule out certain conditions and to help them determine who they should call or consult next, the services they request will often be accurately billed by the requested provider as a consult.



Well Said. Thanks!


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## KimmHall (Jul 10, 2009)

Thank you all so much for your input and honestly I can see both sides a lot more clearly. Basically it will be extremely dependent on the situation. While we do not often see ER patients just the mere thought of doing it wrong was really bugging me. Thanks again so much for taking your time to offer your opinions. I am not here as often as I would like to be but I do value the opinions of my peers very highly. 

You guys have been phenomenal and given me loads of info.

P.S. The rep never said specifically that an ER doc couldn't request a consult but that they did not meet the qualifications of a requesting physician. (I think she was inferring that there would be no return report which I seriuosly disagreed with if there is a shared record).

I hope to see you at the regional in VA!!!!


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