Gastroenterology Coding Alert

Discover how you can create a helpful tool for your consult claims Neglecting your consultation (99241-99255) requirements in 2007 could land you in hot water. The old-school three R's have shifted because, in 2006, CMS issued two statements increasing the documentation requirements for consults.

Important: These are Medicare guidelines only, but private payers generally accept them. Reacquaint Yourself With the 3 R-s Traditionally, you could code a consultation (99241-99255) if the encounter met 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 of provider to a nurse practitioner, physician's assistant, clinical nurse specialist, or certified nurse midwife.

Protect Yourself With Written Reason and Request In 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,- says 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 initiating doctor 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 [...]