General Surgery Coding Alert

Remember different Medicare rules.

If you don’t know the difference between consults and referrals and what that means for your E/M code selection, you could be cruising toward missing payment opportunities — or facing fraud charges.

Read on to learn documentation tips, coverage issues, and payment differences for your consultation and referral surgical cases.

Learn This Ironclad Referral Rule

“Referral normally implies that all or a portion of the patient’s care will be transferred to a new provider,” says Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J.

Note that when a physician refers a patient to another physician, it’s for the treatment of a certain illness or condition, adds Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CPC-I, CCS, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COGBC, COSC, program director Certification Coaching Organization, LLC in Oceanville, N.J.

Key: A referral is called a “transfer of care,” and when your surgeon treats a patient following such a transfer, it clearly leads you to treating your surgeon’s E/M service as a referral, not a consultation.

Which codes? Since we’ve established that referrals are a transfer of care, you should use E/M office or inpatient codes to report these services, says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J.

That means you should code referrals performed in the office with 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…) for new patients and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) for established patients.

Example: At her annual physical, a 34-year-old patient complains of pain and a large recurring bulge near her umbilicus. Her internist diagnoses an umbilical hernia and refers the patient to a surgeon in your practice, where she has not been seen before. Your surgeon meets with the patient in the office and performs a problem-focused history and examination and discusses a surgical plan with the patient. The surgeon performs surgery at a subsequent date and performs all appropriate follow-up care for the procedure.

Solution: You should code the initial visit with the surgeon as 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making). This service pays $44.50 (2017 Medicare Physician Fee Schedule non-facility, conversion factor 35.8887.)

Mistake: If you had erroneously billed this as a consultation, you would have reported 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making), which pays $48.09 (same fee details). That’s a small overpayment, but could amount to a large repayment due and possible fines if you make this error systematically in your practice

Bottom line: A referral means that one physician asks another physician to take over the care of the patient for a specific condition needing treatment. The patient won’t return to the referring provider for additional care for that specific problem.

Finesse Consultation Opportunities

You can see from the prior example that the consultation code pays more than the comparable office E/M code. That actually represents a trend, with consultation codes typically paying more than similar-work office or inpatient E/M codes. That means you can’t afford to miss a consultation when circumstances warrant.

“In the simplest of terms, a consultation is a type of service where another physician or nonphysician practitioner requests a doctor’s advice, opinion, or recommendations about a patient’s problem; that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations,” says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

Remember the 3 Rs: To correctly code a consult, the documentation must reflect three criteria — Requested opinion, Rendered service, and Reported results to requesting provider. If those aren’t documented, you can’t bill a consultation.

Once you’ve identified that your provider did, in fact, perform a consultation, you need to choose the right code to report. Consultations are categorized into two types, as follows:

• Office/other outpatient consultations (99241-99245, Office consultation for a new or established patient, which requires these 3 key components …).
• Inpatient consultations (99251-99255, Inpatient consultation for a new or established patient, which requires these 3 key components …)

Coding Tip: Never use the term “referring physician” when dealing with a consultation, but choose a term such as “requesting physician” instead. This will avoid confusion for both billers and auditors.

Alert: Medicare and some other payers don’t recognize the consultation codes 99241-99245 and 99251- 99255. For those payers, you’ll need to bill an inpatient or outpatient E/M code just like you would for “regular” E/M services (or for referrals, which use the same codes).

Look at the following example to see how different payer rules might impact your consultation coding and reimbursement:

A physician admits a patient to the hospital for high fever, uncontrolled vomiting, and right lower quadrant pain, reporting 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity). After ordering diagnostic tests, the physician asks your surgeon to consult on the case regarding whether the patient should have surgery for possible appendicitis. Your surgeon sees this patient in the hospital, performing a problem focused history and exam, and provides a written report of his recommendation for an appendectomy to the admitting physician.

Solution: Because this is an inpatient consultation, you should report 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making) for your surgeon’s work if the payer accepts the consultation codes.

Medicare: If the payer is Medicare, you can’t use 99251, so you should turn to the initial hospital care codes.

Problem: You can see that the lowest-level initial hospital care code (99221) describes a detailed or comprehensive history and examination, but your surgeon documented only a problem-focused history and examination. Also, the admitting physician already reported 99221 for this patient on the same date.

Do this: You should report 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity) because it matches the level of work your surgeon performed for this patient, even though it’s a “subsequent” not “initial” care code. This is according to CMS instruction due to the decision to make the consultation codes non-payable.

Modifier: Also, if your surgeon’s E/M service had warranted a 99221 or higher initial inpatient care, you should report that code even though the admitting physician also reported an initial hospital care code. Medicare created a modifier to clarify this situation. The admitting physician should append modifier AI (Principal physician of record) to the initial hospital care code to show which doctor admitted the patient. The other doctors seeing the patient for initial consultative services may charge for their services with a code from the same series, but with no modifier.