General Surgery Coding Alert

To avoid being caught up in an OIG investigation, be sure that a visit meets all the consult requirements before billing it as such, and be careful of the language you use to describe the patient visit.
 
Medicare paid $2 billion in 2000 for consultations (99241-99263), and in 2004 the Office of Inspector General (OIG), as outlined in its annual Work Plan, wants to determine if practices are reporting these codes correctly.
 
Don't Be Fooled by Imprecise Terms Just because another physician "refers" a patient to your surgeon doesn't mean you should assume the visit is a referral or transfer of care. Choosing a standard outpatient code instead of a consult (when the consult is appropriate) will cut into your practice's bottom line (because outpatient visits pay less than consults).
 
"Doctors frequently say to patients things like, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.
 
Let the "Three R's" Guide You: Likewise, if the surgeon says he "consulted" with the patient, you shouldn't automatically choose a consult code. A "consult" as defined by CPT describes a very specific service that involves three components:
  a Request from another physician for a consult
  an opinion Rendered by the consulting physician
  a Report on the patient's condition sent by the consulting physician to the requesting physician.
 Using these three criteria, you can separate the consults from the transfers of care. Self-Referrals and Recommendations Don't Count
 
If a patient visits your surgeon on his own accord, or at the "recommendation" of another physician, you must select a standard outpatient E/M code (99201-99205 for new patients, or 99211-99215 for established patients) to report the service.
 
"The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group," says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if "the attending physician did not specifically ask for an opinion or advice from the specialist." This request from the attending physician must be recorded and available as a part of the patient's medical record. 'Some Care' Doesn't Mean 'Transfer of Care' You may report a consult even if your surgeon schedules testing or initiates care for the patient - if the visit meets the requirements of request, render and report.
 
CPT 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."
 
Furthermore, in July 1999, CMS transmittal R1644.B3 [...]