Gastroenterology Coding Alert

Question: We have had instances when we have had to bill for an office consultation without a written request because the referring physician had asked us by phone to do the consultation. However, a coding consultant told us that we should include a written request in the patient's medical record from the referring physician to bill the consultation correctly. Which is correct?

Colorado Subscriber


Answer: According to CPT, you can accept a verbal request from the referring physician for consultations.   The E/M section of the manual states, "The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patient's medical record."
 
Further, the Medicare Carriers Manual (MCM), Section B3 15506, dated August 1999, states consultation guidelines as follows: "A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record. A written report must be furnished to the requesting physician."
 
Regarding documentation, MCM also says, "In an office setting, the documentation requirement may be met by a specific written request from the requesting physician or if the records show a specific reference to the request."
 
So, when your referring physician does not make the consultation request in writing, you should document the "specific reference to the request" in your report for the patient's medical record. You could state something like, "Patient J.Q. was seen this morning in a consultation as per your request of [date] for evaluation of [symptoms]."
 
Also, remember that the CPT guidelines require that you must document the consulting physician's opinion and any services ordered or performed in the patient's medical record, and communicate this written report to the requesting physician or other referral source.
 
For more information, see the March 2003 Gastroenterology Coding Alert Reader Question "Follow Consultation Rules," and the September 2002 article "10 Tips to Differentiate Consultations and Referrals.