General Surgery Coding Alert

Quick: What three requirements distinguish a consult (99241-99263) from other inpatient and outpatient E/M services? If you can't answer, you need to brush up on the "Three R's" of consults - request, reason and response -or you may face audits or denied claims for incorrect coding.

"As specialists, surgeons will see a lot of consults," says Anita L. Carter, LPN, CPC, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J. "Essentially, a consult takes place when one physician seeks the opinion or advice of a second physician, usually a specialist, for the treatment or diagnosis of a patient."

Carter warns that the physician must meet three very specific criteria before you may claim a consult: "I won't even consider reporting a consult code unless the physician has documented the request, reason and report that distinguish a consult from a 'standard' office or hospital visit."

The request is the first of the three elements that distinguish a consult from other E/M services. A consult must be "requested by another physician or other appropriate source" (except in the case of a patient- or insurer-generated confirmatory consult, according to the Medicare Carriers Manual, section 15506. See "Confirmatory Consults Follow Different 'Request' Criteria" for more information).

"The request should be in writing and documented in the patient's medical record," Carter says. "If a request isn't there, a consult didn't take place." In an emergency department or an inpatient or outpatient setting in which the referring physician and consultant share the medical record, the request may consist of an appropriate entry in the common medical record, according to the MCM.

In addition to a request, there must be a documented reason for the consult. "As with any service, the payer wants you to show medical necessity," says Kimberly Jawidzik, CPC, a coder with MedAssure LLC in Minneapolis. "The requesting physician should specify exactly why he or she is asking for a consult - why it is required." For example, if a patient complains of signs, symptoms or conditions indicative of stomach cancer, the requesting physician should note these and ask that the surgeon evaluate the patient's possible problems.

The final requirement to bill a consult is a written response. "The whole point of the consult is to provide an opinion," Jawidzik says. "Following the visit, the consulting physician must prepare a written report of his or her findings for the referring physician." MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician" [emphasis added] and kept as part of the medical record (a "verbal" report is not good enough). Once again, if the physician does not provide a response, a consult has not occurred, and you cannot appropriately bill for one.

For example, a primary-care physician requests a consult with the surgeon for a patient with a suspected hernia. The surgeon must provide a response to the requesting physician outlining his or her findings. If the surgeon does not include this response in the medical record, you can report only a new patient visit (99201-99205) rather than a better-paying consult.

You may bill a consult in addition to "any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of the initial consultation," CPT says. "Even if a consulting physician runs some tests or makes recommendations for treatment, it's still a consult if all the requirements are documented," Jawidzik says.

In July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless of whether treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs. "If the physician doesn't accept complete responsibility for the patient, you can still report a consult, regardless of other services provided," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

If a transfer of care does occur, "The receiving physician would report a new or established patient visit, depending on the situation ... and setting (e.g., office or inpatient)," the MCM states.

In the above example involving the patient diagnosed with intra-abdominal abscess, the surgeon may bill a consult even though he or she also performed diagnostic testing and recommended steps to alleviate symptoms. These procedures/services do not constitute a transfer of care. If the surgeon subsequently assumes responsibility for treatment of the patient, report the visits using the appropriate established outpatient codes (99211-99215) or procedure codes.

Although "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms when requesting or describing a consultation, Carter says. Auditors and payers may automatically consider "referral" or "treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming complete care of the patient, and therefore may not reimburse for a legitimate consultation.