EM Coding Alert

Hint: understand payer guidelines and provide clear documentation for both services.

Most coders are aware of the difference between a patient transferring to another provider and a provider consulting on a patient problem. Yet coding for each situation can be tricky and - in the case of consultation - can impact your practice's revenue stream positively or negatively depending on your knowledge of payer preferences and your coding choices.

So, to keep your coding clear in these situations, read on, and remember to clip and save our advice on how to code consultations correctly when you're done.

Think of Referral as 'Transfer'

A referral means that one physician asks another physician to take over a patient's care before the second physician sees the patient and he accepts the patient for a specific condition that needs treatment, according to Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CPC-I, CCS, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COGBC, COSC, program director Certification Coaching Organization, LLC, in Oceanville, N.J.

"Referral normally implies that all or a portion of the patient's care will be transferred to a new provider," adds Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC, in Oceanville, N.J.

Key: A referral is called a "transfer of care," and when your provider treats a patient following such a transfer, it clearly leads you to treating your provider's evaluation and management (E/M) service as a referral, not a consultation.

Code it:  Because referrals are a transfer of care, you submit E/M office or inpatient codes to report these services. When referral care takes place in the physician's office, choose from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components...) for new patients and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...) for established patients.

Watch for Consultation Opportunities – and Better Payout

Consultation codes usually have higher reimbursement rates than similar E/M codes for either inpatient or office services. That means you don't want to miss a consult coding opportunity when it arises – but you also want to have solid justification for coding the consult.

"In the simplest of terms, a consultation is a type of service where another physician or non-physician practitioner requests a doctor's advice, opinion, or recommendations about a patient's problem; that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations," says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

Remember the Rs: To correctly code a consult, the documentation must reflect three criteria - requested opinion, rendered service, and reported results to requesting provider. If those aren't documented, you cannot bill a consultation. (See the Clip and Save side bar on page 28).

Once you have established that your provider performed a consultation, the applicable codes fall into two categories:

• Office/other outpatient consultations (99241-99245, Office consultation for a new or established patient, which requires these 3 key components...).
• Inpatient consultations (99251-99255, Inpatient consultation for a new or established patient, which requires these 3 key components ...)

Caution: Medicare and many other payers no longer recognize the consultation codes 99241-99245 and 99251- 99255. For those payers, bill an inpatient or outpatient E/M code just like you would for "regular" E/M services (or for referrals, which use the same codes).

At the present time, you're rarely able to use the consultation codes for hospital or office consultations. However, staying aware of the coding guidelines is always a good idea in case an appropriate coding situation arises.

For coding the old consultation office codes note:  Office consultation code 99241 requires a problem-focused history only, which means the provider doesn't need to document an ROS (review of systems). CPT^® code 99242 requires an expanded problem-focused history, which means only a problem-pertinent ROS (one system) needs to be present in the documentation. And 99243 requires clear documentation of two to nine systems to meet the detailed history requirement. As for the highest consultation levels, 99244 and 99245, the physician must document a "complete" ROS to report these codes.