Neurology & Pain Management Coding Alert

Get the Answers to Your Consult and Referral Questions

Published on Thu Oct 02, 2003

Coding expert Nicoletti weighs in with her advice

Don't allow your practice to lose money over consult and referral coding. Let Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H., answer the top nine coding questions for this service:

Question 1: Why is correct coding for consultations important?

Answer: First, we all want to optimize revenue, and we are paid more for consultations than for new patient visits. Consultations are also on the HHS Office of Inspector General's Work Plan this year and have been for the past few years. It certainly got my attention about a year ago when I was visited by two men in suits who flashed their badges at me. One was from the Office of Inspector General, and one was from the U.S. Department of Justice, coming to talk to me about a physician and his consultation code use. So to legitimately and ethically bill for that service and be paid at that higher level, you must know the appropriate criteria of a consultation.

Question 2: What are consultations?

Answer: Consultations are the E/M services that we find in the beginning of the CPT book. They are broken down into office and outpatient consultations (99241-99245), initial inpatient consultations (99251-99255), follow-up inpatient consultations (99261-99263), and confirmatory consultations (99271-99275).

Question 3: Does Medicare define consultation differently than the CPT?

Answer: Yes, and basically the difference is based on who can request a consultation. Medicare specifically states that only a physician, a nurse practitioner, a physician assistant or a certified nurse midwife may request a consultation. That means a social worker, a physical therapist and a nurse are not people who can legitimately request a consultation for a Medicare patient and have the consulting physician bill and be paid for a consultation.

The CPT definition, which some third-party carriers may adhere to, lists the same group as Medicare in addition to "another appropriate source," which may include physical therapists, occupational therapists, speech therapists, psychologists, social workers and even lawyers. When dealing with third parties, I assume they are going to use CPT rules unless I hear otherwise.

Medicare makes no distinction between new and established patients for a consultation, so you can provide a consultation for an established patient as long as you meet the proper criteria.

Neither definition allows a self-referral for a consultation. A self-referral is billed as an office visit or hospital visit or whatever the appropriate type of service is, but not as a consultation.

Question 4: What are Medicare's criteria for billing a consultation rather than a visit?

Answer: To distinguish between a hospital visit, admission, emergency department visit, new or established patient visit or any of those other E/M services, the Medicare Carriers Manual (MCM) gives three criteria for a consultation:

The physician who is providing the consultative service has had his or her opinion requested by another appropriate source. For Medicare, that is a physician, nurse practitioner, physician assistant or certified nurse midwife.

This request for the consultation must be documented somewhere in the medical record so you can prove that it was done.

The physician who renders his or her opinion prepares a written report, which is provided back to the referring physician.

There is a request for an opinion, a rendered opinion, and a report sent back to the requesting physician.

Question 5: How should I document a request for a consultation?

Answer: The documentation of this request provides one of the main distinctions between a consultation and an office visit, and it can be in a number of different places in the medical record:

In an inpatient record it may be the order from the requesting physician written in the physician order notes, which are separate in a hospital admission from the progress notes and everything else.

The request may come in a letter from a requesting physician: Dear Dr. Jones: Would you please see Betsey. I need your opinion about her new onset headaches.

It can also be documented in the first sentence of the consulting physician's report: I am seeing this patient at the request of Dr. Jones for my opinion about her stomach pain.

Some practices ask their requesting physicians and providers to fill out a form with a number of options that the requesting physician checks off.

Typically the consultant generates a form requesting a consult and provides a copy to the requesting physicians, asking them to fill out the form and send it with the patient's medical records. The downside is that if you are the primary-care office and you have to fill out a form to send the patient to orthopedist A, while orthopedist B allows you just to make a phone call, you might end up sending that patient to orthopedist B because he or she has made access easier. But this might make your office less patient-friendly.

Question 6: What should I look for in the documentation?

Answer: A common medical record both in the hospital and in a group medical practice is sufficient as a report. Do not forget that if you are not using a common medical record, it is not a group practice, or it is not an inpatient consultation, there needs to be proof that you sent the report back to the requesting physician.

Here are a couple of reports with first sentences that do not meet the criteria for a consultation:

1. Dear Dr. Jones: Thank you for sending me your patient. I see a lot of patients who are sent for their headaches. The request for the opinion is not documented. It is clear that the patient was sent, but it is not clear that there was a request for an opinion.

2. The patient is a 55-year-old male referred to me for treatment of his back pain. There is no request documented for an opinion, and you do not know how the patient was sent or who referred that patient.

Here are two examples of consult reports that successfully meet the criteria for the documentation in the first sentence or two:

1. Dear Dr. Jones: Thank you for requesting my opinion about Betsey's headaches. They are common migraines. Here, we clearly have the documented request. We also have the rendered opinion - common migraines. And we have sent the report back to the requesting physician, as indicated by the letter.

2. For a preoperative examination consultation: Dear Dr. Jones: At your request I have evaluated Ms. Hipp's medical condition prior to surgery. I find her medical problems to be A, B and C, and she is cleared for surgery. You have the documentation of the request, and the physician has rendered an opinion.

Question 7: In selecting the CPT code, when can I use time as the determining factor instead of using the three key components of history, exam and medical decision-making?

Answer: According to the CPT manual, you can use time in selecting a code when it is a face-to-face service and more than 50 percent of the visit is taken up in counseling and coordination of care. CPT defines counseling and coordination of care as a discussion with the patient and/or the family about the illness, but remember that for a Medicare patient you need to have the patient there with you. Just talking to the family is not enough. There are three very specific things you need to document:

the total time of the visit

the fact that more than 50 percent was counseling

the nature of the counseling.

A visit in which time determines the level of service for a consultation would, for example, be a patient whose primary-care doctor requested the opinion of a gynecologist regarding whether a patient should remain on hormone replacement therapy. The patient goes in to see the gynecologist and says, "I do not need an exam today. I just want to talk to you about what to do." You are using the three key components of history, exam and medical decision-making, but that visit becomes unbillable because the physician doesn't perform a physical exam. Or maybe the doctor has the patient's vital signs, in which case you could bill the service as the lowest-level consultation, which doesn't fairly reflect the amount of time the physician spent with the patient. Another example would be when a patient visits a surgeon, has a minimal exam, and spends the rest of the visit discussing the risks and benefits of surgery as an option for his care.
Whenever you are using time to assign a consult code, documenting the time on the encounter form is not enough. The doctor must document it in the medical record. The only caveat to this is confirmatory consultations, which you cannot bill using time as your determining factor. CPT does not use time as a defining factor for 99271-99275. Those must be billed using the three key components.

Question 8: When can I bill a consultation for a preoperative clearance?

Answer: Your physician can perform preoperative consultations for a new or established patient at a surgeon's request as long as all of the requirements for the consult codes are met and medical necessity is documented.

One of the problems with preoperative visits is that the surgeon doesn't make a direct request for a consultation. The patient arrives with a form and says, "Please fill this out before I have my knee surgery done next week." That is not a request for an opinion. What happens is that the physician or the nurse practitioner or physician assistant fills out the form with the appropriate history and examination and sends it not to the operating physician or to the surgeon, but instead to the hospital or surgery center.

Another problem with these visits is that the form usually has very little room for the history of present illness. If there is little or no history of the present illness - for example, "She is here because her hip has been bothering her" - those notes audit down to the lowest level, even when the consultation request has been documented and the service was performed and the note sent back to the requesting physician. Take a look at those forms, and if they are not giving your physicians room to write the history of the present illness, you should either get them to dictate a note or get the hospital or surgery center to amend the forms.

Question 9: How can we evaluate the accuracy of our current consultation coding?

Answer: In your office, print a report of the consultation visits that you provided in the 99241-99275 series and randomly pick out five for each of your providers. You are probably not going to audit the level of service, but determine if the consultations are being documented appropriately. Was a request for an opinion documented? Was the report sent back to the requesting physician? If it is very clear that they meet the criteria, you can breathe a sigh of relief. But if not, and you want to change your ways about consultations, educate everyone about what is or is not a consultation and make everyone understand how to document a consultation appropriately.