Reader Question: Documenting Consults

Question: Recently our carrier has been downcoding our consult claims to established patient E/M visits. What are we doing wrong?

Kansas Subscriber

Answer: The problem may be your documentation. First and foremost, you must demonstrate that all requirements for billing a consult (99241-99245) have been met. These include:

1. Request: A consult is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

2. Reason: A request for a consultation from an appropriate source and the need for consultation (medical necessity) must be documented in the medical record.

3. Response: After the consultation, the consultant must prepare a written report of his or her findings that is provided to the referring physician.

Medicare Carriers Manual (MCM) guidelines specify that the consultation report must be "a separate document communicated to the requesting physician."

Even if you meet the above requirements, some payers may reject consult claims if the language of the requesting physician is unclear. Therefore, physicians should avoid the terms "referral" and "consult and treat" when requesting or describing a consultation. Auditors and payers may automatically consider "referral" or "consult and treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming complete care of the patient (i.e., a complete transfer of care has occurred), and therefore may not reimburse for a legitimate consultation. A better choice when requesting a consult is to use language such as "Please examine patient and provide me with your opinion on his or her condition." Generally, the consultant has no control over the language used by the requesting physician. Therefore, the consultant has to make it clear in the chart and in the letter that only his or her opinion was requested and that a complete transfer of care did not take place.

In addition, some payers have not reimbursed consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans. This is incorrect, and you should appeal such denials.

A July 1999 HCFA (now CMS) transmittal, R1644.B3 (effective Aug. 26, 1999), clarified that Medicare will pay for a consult regardless if treatment is initiated or not, as long as all consultation criteria are met and no transfer of care occurs. The MCM, section 15506 further explains, "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance." "Referral," in this instance, is simply another term for transfer of care.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company, and Teresa Thompson, CPC, an independent allergy coding and reimbursement specialist in Sequim, Wash.