Cardiology Coding Alert

Report in-house EP consultations with these documentation tips

Don't allow your carriers to confuse a consult with a transfer of care. By reviewing your cardiology consultation basics, you're certain to get your consult claims paid every time.

In a nutshell: A consultation occurs when a physician, other healthcare practitioner, patient or other third-party requests that your cardiologist render advice on a specific problem a patient is experiencing. Use this strategy to differentiate between some common types of consultations to ensure accurate reimbursement.

Clue in to These Consultation Components

Office consultations occur when a physician or other healthcare provider (such as a nurse practitioner or physician assistant) requests the opinion of another healthcare provider.

You should report office and other outpatient consultation codes (99241-99245) when your cardiologist provides a consultation in the office or other outpatient setting, such as the patient's residence, a hospital observation unit, or an emergency department.

Example: A patient presents to his primary-care physician (PCP) with unexplained cardiac symptoms (such as chest pain, shortness of breath, arrhythmias, abnormal EKG findings or preoperative assessment dealing with a cardiac history). The PCP asks a cardiologist for his opinion. "Some PCPs will request an opinion only, but others will ask the cardiologist to 'consult and treat,' which means the cardiologist would relay his findings along with a suggested treatment plan to the PCP," says Ann Scott, CPC, ACS-CA, CCS-P, business office manager at Mid-Ohio Heart Clinic in Mansfield.

Note: Although having the request from the physician in writing is not necessary, you must be sure that the patient encounter documentation specifically states that the visit is for a consult, not for a transfer of care, says Bethany Grizzafi, CPC, senior coding specialist at the University of Texas Medical Branch in Galveston.

Most often, physicians of different specialties, such as a family practitioner and a cardiologist, arrange consultations. However, sometimes a physician may want a consult within his specialty.

Your Challenge: Coding for Subspecialist Consults

For cardiology groups with electrophysiologists (EP) or other subspecialists (such as peripheral vascular specialists) in-house, coding consultations presents a unique challenge. Many coders ponder the following question: "If a cardiologist requests a consultation from a subspecialist physician in the same practice, can the EP physician bill his service as a consultation rather than an established patient visit?"

Although considerable differences separate EPs from other cardiology subspecialties, Medicare has not established a separate designation for EPs. On the credentialing paperwork (such as the CMS-855), EPs must designate themselves as "cardiologists." This lack of specificity on registration forms works against EP physicians because, based on the above guidelines, these physicians are in the same group, in the same specialty, and may not be able to secure reimbursement for services that they report as consultative if a cardiologist within the same practice requests the consult.

Many practices, however, have reported success collecting consultative reimbursement for their EP physicians when group-member cardiologists request consultations. Because many cardiologists characterize electrophysiology as a distinct subspecialty of cardiology, relatively few diagnostic or therapeutic scenarios overlap.

Think of it this way: "Your cardiologist works on the 'plumbing' portion of the heart (making sure all the pipes or arteries are clear from blockages), while your electrophysiologist keeps the 'electrical' portion of the heart going--in other words, keeping the heart from missing a beat," says Joanna Anderson, CPC, billing manager and coder at Peninsula Cardiology Associates in Salisbury, Md. "So when your cardiologist refers his patient to your EP to render an opinion and report back on the electrical portion of the patient's heart, then you can report a consult."

Caution: In general, intraspecialty consults can be more difficult to obtain reimbursement for, but Medicare guidelines do say that if a consult is within the same specialty and is medically necessary, it will pay for it, says Teresa Thompson, CPC, CEO of TM Consulting and a certified multispecialty coding specialist in Sequim, Wash.

Tip: To avoid problems, note in the report that the consulting physician is subspecialized in a unique part of his field, Thompson says.

You should also be sure your documentation meets the requirements of a consult, which include (a) medical necessity, (b) the request from an appropriate practitioner seeking advice or an opinion, and (c) the results or opinion of the cardiologist, which he reported back to the requesting physician, Scott says.

Strategy: Another good tactic for reporting subspecialist consults is to have the EP provide the consultation on a different day than when the requesting physician sees the patient.

On the rare occasion when your EP (or other subspecialist) is able to work in a same-day consultation, you should prepare yourself for administrative burden and payment delay. The reason is that your report will likely be pitted against Section 15501(H) of the Medicare Carriers Manual (MCM). The MCM states that a physician in a group practice who performs an E/M service for another physician of the same specialty should report only one E/M service per day. The exception is if the E/M visits are for unrelated problems.

Note: You can read this section in its entirety at http://www.cms.hhs.gov/manuals/14_car/3b15052.asp.