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 [...]