Internal Medicine Coding Alert

Internal medicine practices should have an easier time receiving appropriate payment for preoperative clearances and other consultations on Medicare patients following recent clarifications by the Health Care Financing Administration (HCFA).

HCFAs guidelines for the use of consult codes were relaxed this year, advises Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. The guidelines have been changed. HCFA is not requiring a written request from the requesting physician.

In addition, HCFA has stipulated to carriers that preoperative examinations performed to clear patients for surgery are reported appropriately as consultations, says Brett Baker, third-party relations specialist with the American College of Physicians-American Society of Internal Medicine (ACP-ASIM). They have said that these examinations should be reimbursed (as consultations) as long as all of the requirements for a consultation have been met, Baker says. (See Understand Coding for Preoperative Clearance Exams on page 13.)

What is a Consult?

The term consultation often has been used to mean services other than what CPT defines as consult visits.

One of the big areas of confusion is when a physician asks the internist to see a patient and assume care of that patient (i.e., come to the emergency room), says Cynthia Thompson, CPC, senior consultant with Gates, Moore, and Co., an accounting firm in Atlanta, Ga. Remember, a consultation requires the request for the internists professional opinion in order for the original physician to continue treating the patient.

Sometimes, a patient may call the office and request a consultation with the physician, she adds. These visits are not an appropriate use of consult codes.

You need the requesting physician to be clear about whether they are asking for an opinion or they are assuming that you will treat the patient for a particular problem, says Thompson. To help eliminate confusion, Thompson has designed a form for physician practices to use when seeking consultations from specialists and when honoring requests for consults from other physicians. (See insert Referral/Consult Form in this issue.)

In addition, she notes, mandatory second opinions, such as those required by some third-party payers, are not reported with inpatient (99251-99255 and 99261-99263) or outpatient (99241-99245) consult codes. These are reported with the category of confirmatory consult codes, 99271-99275, she notes.

The Three Rs

The best rule to use when deciding whether or not to report a consultation code is the three R concept, says Brink. To report a consultation, you need a request for an opinion, a review (exam) of the patient and a written report to the requesting physician stating an opinion, she explains.

Note: Although a written request for a consult is not required, the consulting physician is required to make a written report of his or her medical opinion back to the requesting physician, Brink emphasizes. Under the old guidelines, you could either make a written or verbal report, now it must be a written report.

For example, a general practitioner or family physician suspects a medical condition (i.e., diverticulitis) in a patient; he sends the patient to an internist with a request for an opinion on whether the patient has this condition. The patient is seen by the internist, who examines the patient, perhaps orders some tests and/or prescribes medicationyou can do this during an initial consultationand renders a clinical opinion, which he reports back to the family physician, she says.

CPT 2000 has included expanded language in the introduction to the consultation section to clarify when a visit should be reported as a consultation. Although the request for an opinion does not have to be in writing, the consulting physician should include in his documentation the fact that the visit is at the request of another physician, Brink adds.

It is very important that the medical record states this because it provides the first documentation requirement for coding a consult, she says. The physician should document a statement such as, Patient is here today for a consultation at the request of Dr. Smith.

Follow-Up Consultations vs. Visit E/M

Knowing when to report a follow-up inpatient consultation instead of a subsequent hospital visit evaluation and management (E/M) code also is confusing. The key, says Brink, is whether the consulting physician has completed his or her medical decision-making and formed an opinion in the initial consultation.

In the previous example, if the internist saw the patient for an initial consultation and ordered tests to determine his final opinion, he would need to see the patient again to complete his medical decision-making and render a final opinion, she says.

For the first visit, the internist would see and examine the patient, send the patient for tests and send a report to the requesting physician stating that additional tests were required to make a final determination, says Brink. He would report back to the family physician that I believe Ms. Jones has a bleeding ulcer, but I have sent her for further tests and prescribed medication. I will see her again in two weeks to make a final determination.

At the two-week visit, when the internist renders his final opinion to the requesting physician, a follow-up consultation code would be reported, Brink says.

However, if a physician sees a patient for an initial consult, then assumes care of that patient for that medical condition, all follow-up visits would be reported with regular visit E/M codes, she says.

Brink gives an example of an orthopedic surgeon who is going to perform surgery on a patient with a fractured hip, but is concerned that the patient may have a heart condition. A consult goes out to an internal medicine physician specializing in cardiology. The consultant sees the patient, examines the patient, possibly orders tests and makes an opinion. That is a consult. However, if he continues to see the patient for that problem, the subsequent visits are not consults, they should be reported with E/M codes, she says.

Note: For more information on reporting consultation codes, see the article Correct Coding for Consults and Referrals: Dont Confuse a Request for an Opinion with a Transfer of Care on page 17 of the March 1999 Internal Medicine Coding Alert.