Neurology & Pain Management Coding Alert

You can request consults from same-group colleagues, but watch frequency

You may have spotless documentation for your consults (99241-99255), but you could still lose every penny of consult reimbursement in an audit, thanks to some new CMS rules.

In a recent transmittal, the Centers for Medicare & Medicaid Services says that you must have documentation of the consult request in both the consultant's records and the requesting physician's records. The request must also be part of the requesting physician's plan of care for the patient.

The new requirement for the requesting physician to document the request for a consult is -a Catch-22,- says Steven Levinson, Connecticut-based author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care. -If I call the doctor who's referring me patients every six days, and say -Please send me a photocopy of your chart that shows you documented the consult,- I soon will not have any consults.-

Bring Requesting Physicians on Board

As Levinson says, complying with CMS- new rules on consult documentation will be a challenge, but you can audit-proof your system using the following tips:

1. Document, then consult: It's not enough for the requesting physician's file to have the consulting physician's report after the fact. The request must be in the requesting physician's chart before the consult happens. If your surgeon performs consults, you should educate the requesting doctor's staff about this new requirement.

2. Standardize requests: Create a form that you can fax to the requesting physician's office for documentation of the reason for the request, says Patricia Trites with Compliance Resources in Augusta, Mich. The requesting physician can keep this form in the medical record.

3. Separate report: If you are serving as the consulting physician, make sure you do your part by writing a separate report of your findings and opinion, says Trites. Send that report to the requesting physician. In the inpatient setting this report can go into the same medical record for the patient, but in the outpatient setting carriers have instructed that this must be a separate record.

Watch Same-Group Consults and Transfers of Care

In addition to requiring double-duty on documentation, the CMS transmittal also explains that a physician or NPP can request a consult from another physician or NPP in the same group, as long as the consultant has -expertise in a specific medical area beyond the requesting professional's knowledge.-

CMS also clarifies that a consult isn't the same as a transfer of care, and the consultant shouldn't take over the management of the -patient's complete care for the condition.-

Instead: For a transfer of care, you should bill the appropriate new or established patient evaluation and management code.

Follow these tips to navigate these two tricky areas:

- Consult with care: It's always been true that a physician could request a consult from a colleague in the same group, but CMS has now highlighted this fact, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a healthcare coding consultant in Laguna Beach, Calif. This clarification adds pressure to physicians to make sure they-re not making frivolous consults within the same group.

- Don't churn: Some practices have a protocol in which  patients will come in to see Dr. A, and Dr. A automatically sends the patient to see Dr. B, says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York. The feds will -see it as a sort of churning.-

- Return to sender: The consulting physician should make a point of returning the patient to the requesting physician. This shows that the consult wasn't a transfer of care. Returning the patient also allows the physician to bill for another consult if the requesting physician needs more information about that patient in the future.