Cardiology Coding Alert

If you fail to document the request, you could land in hot water

If you're planning to start 2007 right, reviewing your consultation (99241-99255) requirements should be high on your to-do list.

Reality check: The old-school three R's have shifted. In 2006, CMS issued two statements increasing the documentation requirements for consultations.

Important: These are Medicare guidelines only, but private payers generally follow them.

Reacquaint Yourself With the 3 R's

Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:

• Request for opinion

• Rendering of services

• Report to the requesting source.

First on Medicare's chopping block were qualifying requesters. The new CMS guidelines require a physician or qualified nonphysician practitioner (NPP) to make the request. CPT specifies, however, that the request can be from a physician or other appropriate source.

Note: Medicare limits the definition for the NPP category to a nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse midwife.

Protect Yourself With Written Reason and RequestIn December 2005, CMS added "reason" to the consultation R's. Transmittal 788 requires that the requesting physician or NPP document the request and the reason for a consult in the patient's medical record. This advice existed as spoken instruction, but it had never before been given in writing, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Helpful tool: To help ensure that requesting physicians meet the new requirement, Cobuzzi suggests creating a reverse request fax consultation form. Consultants can fax the form to the requesting physician to be filed in the patient's chart. "We can't make [the requesting source] file the form, but using the tool at least increases the chances that there is something in the chart," Cobuzzi says.

CMS Partially Lets Consultants Off the Hook

The ensuing paperwork trail led CMS to reconsider the feasibility of making the consultant responsible for the requesting physician's documentation. "On April 18, 2006, the PRIT (Physician Regulatory Issues Team) released a statement stating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient's chart," writes Diane Daigle, president of Maine Medical Group Management Association. When an appropriate source requests a consult, the consultant isn't responsible for making sure the requesting physician's files include that request in writing.

That's not all: CMS officials still insist that the requesting physician has to document the request for a consult. The only change is that the consultant doesn't have to verify that the requesting physician has done so.

So what will happen if a carrier audits the consultant and doesn't find any request documented in the requesting physician's files? Will the consultant still get paid? At this point, CMS hasn't been able to answer that question.

"It is a real paper chase for the consultant to have to look at the requesting physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif.

The issue isn't resolved: CMS officials say they're not planning to clarify the consult issue any further -- unless providers or carriers indicate that they're still having problems. CMS doesn't even plan to issue a transmittal or manual update spelling out this latest clarification, which partly lets consulting physicians off the hook.

Best advice: As always, you should let documentation guide your coding. Now more than ever before, the consultant must have a reason and request for the consult documented in the patient's medical record, along with an opinion rendered by the consulting physician, with a written report sent to the requesting physician.

Look for Complete Circle of Care

Experts also recommend adding the "fifth R" of returning (or discharging) the patient back to the requesting physician when the episode of care is complete.

Remember: The "return" does not always occur at the end of the consultative service. "The consultant is permitted to initiate treatment, when appropriate, and still report a consultation," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
 
When the consultant completes the course of treatment, eventually discharging the patient from his care, a notation in the medical record helps distinguish between ongoing care and future consultation requests, Pohlig says.

Refer to the New Consultation 5 R's

Keep the consultation requirements straight with these basics. The five R's of a consultation are:

Reason: Both the requesting and consulting physicians must document a medically necessary reason and request for a consultation. But the consultant doesn't have to verify that the requesting physician did so.

Request: The request must come from another physician or qualified NPP. CPT also allows requests from other appropriate sources, so check with your  payers to determine what they consider valid consult request sources.

Render: The consultant must render services during which he may initiate diagnostic and/or therapeutic services.

Report: The consultant must issue a written report of his findings to the requesting source.

Return (recommended by consultants): To show that a transfer of care has not occurred, the consultant should send the patient back to the referring physician.

Example: A primary-care physician (PCP) has been monitoring and treating a 78-year-old established patient for known congestive heart failure (CHF) over a period of time. Based on recent findings, the PCP requests a cardiology consultation. The intent is to obtain an opinion and advice relevant to the status of the patient's CHF, current treatment, revised therapy, new therapy, recommended monitoring, and any other clinical needs.

The consulting cardiologist evaluates the patient. He then documents the reason for the PCP's request and his recommendations for management, and reports this to the PCP. He returns the patient to the PCP's care. The PCP accepts the recommendations and implements the plan of care.

In this case, the consulting cardiologist should report the applicable consultation code from among office or other outpatient consultation codes (99241-99245).