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." 1. Get the Request in Writing 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. 2. State the Reason for the Visit 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. 3. Prepare a Written Response 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 [...]