General Surgery Coding Alert

Question: Can we report a consult if an emergency department (ED) physician refers a patient to our office for follow-up? If so, do we have to send a report to the ED physician? Usually that physician doesnt keep the records and will never see the patient again.

Delaware Subscriber

Answer: You must always meet three requirements (the "three Rs") to report an outpatient consultation:

1. A written request must appear in the medical record.

2. The requesting physician must state the reason (i.e., medical necessity) for the consult. According to the Medicare Carriers Manual (section 15506), "In an emergency department or an in- or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request may consist of an appropriate entry in the common medical record."

3. The consulting physician must provide a written report of his or her finding to the requesting physician.

Note that the U.S. Office of Inspector General is especially interested in inappropriate consultation billing. Therefore, unless you can demonstrate unequivocally that the surgeon has met all requirements of a consult, you should instead report a new or established patient visit (i.e., 99201-99205 or 99211-99215), as appropriate.

In the case you describe, the ED physician is responsible for a single episode of care specifically while the patient is in the ED which terminates when the patient discharges from the ED (in contrast to a primary-care physician, who retains responsibility for the patient). Consequently, the ED physician has no justification to request a consult, i.e., he or she gains no benefit in receiving a report of the consulting physicians findings because he or she will not see the patient again. Therefore, your physician must report a new or established E/M visit, not a consult. A letter from the ED physician referring the patient to your physician constitutes marketing/referral/ relationship building and not a request for a consultation.