Anesthesia Coding Alert

Yes, You Can Bill for Consults

Published on Thu May 13, 2004

Follow these 3 tips to know when to report them

Medicare is increasing its audits of consults versus referrals, which means you need to be extra sure you're correctly documenting and coding cases. Read on for three great tips on knowing when you can legitimately bill a consult instead of a referral.

Tip 1: Distinguish Between Consults and Referrals

For accurate consultation coding, you need to start with learning some basic definitions. Medicare defines a consult as a patient encounter that includes:

a formal request from another physician or provider for a second physician to provide an opinion

documentation of the request in the patient's chart, stating the reason for the patient's visit and what opinion is sought

formal written communication back to the requesting physician concerning the patient's visit and status (not just a copy of the second physician's notes).

Many coders are familiar with this list, or some variation of it, known as the Three R's (request, render and report) of consultations. The confusion lies in Medicare's rule regarding transfer of care or "taking over the patient's treatment," as well as basic terminology crossover.

"The true definition of a consult is rendering an opinion," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. "If the physician needs to initiate diagnostic and/or therapeutic services at the same visit or at a subsequent visit, that's OK and it's still a consult."

"When coding professionals refer to 'referrals,' we're not talking about managed care," says Jann Lienhard, CPC, a coding consultant with SM/art Performance in Philadelphia. "We're talking about consults and referrals based on CPT4. The onset of managed care and the use of the same terminology has led to mass confusion in the entire industry."

Many pain management specialists believe they should always bill "consults" because they aren't the patient's primary physician. But if the "sending" physician's intent is to "transfer patient care" for that particular problem, the pain management specialist (in this case) becomes the treating or primary physician. And that means you report the service as a referral, not a consult.

An example: Many pain management patients are referred to a specialist for treatment. Referring (sending) physicians often use phrases such as "Evaluate and treat," "Refer to Dr. X for low back pain," or "Consult and treat" in their paperwork. These are all new patient referrals because the pain physician is being asked to perform some type of treatment -- rather than simply offer an opinion on the case -- and should be billed as such. Choose the appropriate E/M code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) for the visit, depending on the level of service documented and medical decision-making necessary.

Hammer and Lienhard offer three other considerations that help you clarify whether to code the encounter as a referral or consult:

Clarify what the "sending" provider wants. Is he asking for the pain specialist's opinion, for him to perform a procedure, or for him to take over the patient's care? "I like to see pain management providers create a form they can give to their referral sources," Hammer says. "It can have check boxes to clearly indicate what the sending provider is requesting and include information about scheduling the patient's visit." Tip: A one-page form with this information can easily be incorporated into the patient's chart as documentation of a request for the pain practitioner's opinion or service.

Check the service the pain management physician provided. If he performed a diagnostic service such as a diskogram, you can code a consult because he provided a diagnostic test instead of taking over the patient's care or rendering treatment.

Read your physician's note to the original physician. Pain management documentation often includes phrases such as, "Thank you for allowing me to evaluate and participate in X case" or "Thank you for referring X to me for treatment of Y." Hint: Lienhard recommends having a follow-up template that outlines the physician's findings as well as thanks the "sending" physician for the opportunity to assist in the patient's care and offers additional assistance with the case.

Tip 2: Know When You Can -- and Can't -- Code the Visit Separately

Neurologists, neurosurgeons or other physicians often refer patients to pain management specialists for epidural steroid (ES), trigger point (TP), occipital nerve and other one-time or ongoing series of injections. Many coders struggle with whether to bill the initial visit as a consult or referral or whether reporting any E/M code is appropriate.

The answer is simple -- yes, you can code an E/M visit as a new patient visit, or even as a consult, depending on the provider's documentation and how the sending physician stated his request.

Verify: "The key is whether the documentation indicates that there was a significant and separately identifiable service performed beyond the normal required pre-operative work that's included in the procedure code," Hammer says. "If it does, you can code an E/M service with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)."

Justify: Consultants such as Hammer recommend having additional documentation of the three key components (history, exam and medical decision-making) that exceeds the normal requirements for preprocedure workups. Documenting specific details helps justify using E/M codes for the service. Many pain specialists perform a full E/M evaluation to determine if there are other causes of pain or if the pain has affected other body systems. These physicians want to be aware of the patient's total medical condition prior to performing any injections or other procedures.

Report: When you do code the visit separately, report the most accurate choice from 99201-99205 for a new patient visit. Report a consult with the appropriate code from 99241-99245 (Office consultation for a new or established patient ...).

Another issue arises if a patient who was originally considered a consult returns to your group. These follow-up visits often complete the initial consultation, Lienhard says. Code them as an established patient E/M visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Tip 3: Remember, Cases Can Go Either Way

Some practices tend to have more consults, and others tend to have more referrals, depending on the pain management provider's subspecialty. Those who focus more on medication management and perform few procedures tend to have more consults. Specialists who are more procedure-driven and do little patient management usually have more new patient visits -- or no E/M visit at all.

Whichever category your group falls into, be aware that Medicare is focusing more on consult and referral coding. Audit the documentation to ensure that providers correctly record their services and verify the sending provider's intent to help you accurately report services. As Lienhard says, "Don't follow the check marks on the paper -- follow what the referring provider wants."