Gastroenterology Coding Alert

You can use a fax-back sheet to help meet new documentation requirements

According to a recent Medlearn Matters article, you-ll need to be much more careful about the documentation you cite to support consultation services, and you-ll need to do it immediately.

From this point forward, CMS says both the consulting and requesting physicians must maintain written evidence of a consult.

Reason and Request Must Be in Writing, Twice

Starting Jan. 17, to report a consult (99241-99255), the consulting physician must receive and document a request from an appropriate source, and -the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified NPP's plan of care in the patient's medical record,- according to Medlearn Matters article MM4215 [emphasis added].

So what? These requirements--that the requesting physician must document the reason and request in the patient's plan of care--are new.

In the past, Medicare rules did not specifically state that consultation requests had to be in writing, nor did they indicate that the requesting physician had to note the request in the patient's record (see -Written Consult Request Isn't Mandatory- on page 6 of the January 2006 Gastroenterology Coding Alert).

Keep in mind: The new regulations apply only to Medicare payers.

Example: If one physician meets another in the hallway and verbally requests a consult, they should both document that fact, said CMS official Kit Scally during a Jan. 20 physician Open-Door Forum. If the physician phones in the consult request to the other doctor's staff, both practices should document that circumstance too, she said.

Potential glitch: -The request and reason have to be in both charts,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. -But the consultant only has power over his own chart. The specialists will have to educate the requesting doctors to make sure they make notations of these consultation requests so that the loop is closed.-

The new requirement for the requesting physician to document the request for a consult is -a Catch-22,- says Steven Levinson, MD, of Fairfield, Conn., author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care. -If I call the doctor who's referring me patients every six days and say, -Please send me a photocopy of your chart that shows you documented the consult,- I soon will not have any consults.-

Look to a -Fax-Back- to Ease the Burden

One way to ensure that all necessary documentation is in place for your office to report a consultation is to use a standard -consult sheet- that the consulting physician faxes directly to the requesting physician's office, Cobuzzi says. The requesting physician can fill in the necessary information and include the sheet in the patient's chart, thereby -closing the loop.-

-You can't make the requesting physician fill out the form, but it at least increases the chances there is something in the chart,- she says. -Cooperation will be necessary if consultants are going to receive reimbursement for legitimate services they render.-

Take the lead: When you are sure that a requesting physician intends for you to provide a consult, you can take the initiative to fill in all the relevant information and fax the request form directly to the requesting physician, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C.

-I-m not suggesting upcoding or -creating- a consult when none exists -- but you do want to be sure that you can bill for a consult if you are providing that service. Faxing the -reverse request- form to go in the requesting physician's chart not only fulfills the documentation requirement, but if the requesting physician did not intend to send a consultation, she can simply let you know,- Dunaway says.

Free resource: Find a sample consult sheet in this issue.

One more tip: The consulting physician should make a point to -return- the patient to the requesting physician, Cobuzzi says. This shows that the consult wasn't a transfer of care. Returning the patient also allows the physician to bill for another consult if the requesting physician needs another opinion for that patient in the future.

Another important guideline in Medlearn Matters article MM4215 specifies that qualified nonphysician practitioners (NPPs) can request and provide consults (99241-99255) as long as the services are within the scope of their state license. Because rules vary from state to state, you-ll have to check your local requirements before allowing any of your NPPs to request or provide a consult service.

Note, however, that NPPs cannot provide consults in the facility settings, even in collaboration with a physician, according to CMS guidelines.

Important point: Remember, if the NPP provides a consultation, she is also designing a plan of care. This means that the NPP should report her service under her own PIN, rather than -incident-to- the physician.

The Medlearn Matters MM4215 article also clarifies that a physician can provide a consultation for another physician of the same specialty if the consulting physician's knowledge and expertise go above and beyond that of the requesting physician.

Be wary: Cobuzzi warns, however, that -intra-specialty- consultations could be an opportunity for abuse.

-It has to be clear that the physician in the group being asked for the consultation truly has a skill set that the requester does not have and that this is not being used just to get another consultation,- she says. -I think practices have to use this with care and not too often.-

Bottom Line: Rely on Documentation

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

Cobuzzi would also add the -fifth R- of returning (or discharging) the patient back to the requesting physician when the episode of care is complete.

One rule that never changes: Finally, if the consulting physician assumes full care of the patient's problem, a consult isn't appropriate, even if you meet the above requirements.

Go to the source: You can read Medlearn Matters article MM4215 on the CMS Web site www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.