Internal Medicine Coding Alert

Question: To use a consultation code, a coworker thinks we should make sure the requesting physician also documented his request. Is this a consultation requirement?


New Jersey Subscriber

Answer: Coding experts have always suggested that the requesting physician's chart should refer to the consultation request. But no formal policy had made this a consultation requirement until now.

What's new: Medicare recently stipulated that a consultation also requires documentation in the requesting physician's chart. Originally, CMS stated that the consultant had to document in the patient's medical record the "request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service)." But MedLearn Matters article 4215 also adds that this documentation must be "included in the requesting physician or qualified NPP's plan of care in the patient's medical record."

The impact: Although not required in CPT, anticipate that private payers may adopt Medicare's new requirement and expect a properly documented request to include substantiation by the requesting physician.
 
Experts recommend that the consulting physician request, at the time of booking the appointment, that the requesting physician fax documentation of the request for consult on his letterhead or prescription form. This removes any perception that the consulting physician created the need for the consult when in fact the visit was a referral.

Example: A urologist requests that an internist make sure a patient with hypertension and diabetes is healthy enough to undergo a nephrectomy for rectal bleeding.

The internist:

• requests a faxed copy of the urologist's finding including a request for consult, and she also faxes the requesting physician a copy of her findings and a "Verification of Request" form stating that Dr. Urologist requested Dr. Internist's opinion on Patient A's suitability for nephrectomy.

• documents that he is seeing the patient at the request of Dr. Urologist to make sure the patient is clear for a kidney biopsy.

• performs an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making
 
Code a level-two consultation as 99242 (Office consultation for a new or established patient ...) and sequence using ICD-9 guidelines V72.83 (Other specified pre-operative examination), 569.3 (Hemorrhage of rectum and anus), 401.1 (Essential hypertension; benign) and 250.xx (Diabetes mellitus).

Because you have made every effort to substantiate the service's three R's--request, render and report--and have clear documentation of your role, your consultation charge should pass an auditor's scrutiny.

Download the Medicare consultation service instructions from www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.