Neurology & Pain Management Coding Alert

Question: We've heard conflicting information about the requirement for a written request before our physician can bill for a consult. Must the request be in written form from the requesting physician, or can our neurologist (the consulting physician) merely note the request in the patient record?


California Subscriber


Answer: Best practice dictates that you receive a written request for the consult from the requesting physician. This verifies, without a doubt, that the requesting physician intended for the neurologist to provide a consult (rather than to assume care of the patient) and provides solid documentation to back up your choice of a consultation (rather than standard inpatient or outpatient care) code. But, nothing in CPT or CMS guidelines absolutely requires a written request to report a consult.

The Medicare Carriers Manual, for instance, says the patient's record must have a written "notation" of the request for consult, but it does not specifically state that the request itself must be in writing. Often, in fact, one doctor will call up another, or meet him in the hallway, and request a consultation verbally. In such cases, the consulting doctor should simply write in the patient's progress notes that she's evaluating the patient at the request of Doctor X.

CMS also released a "Medlearn Matters" article (SE-0515) late last year that stated definitively you don't need a letter from the requesting physician to prove a visit was a consult. Rather, you just needed a note in the patient's medical record. To confuse matters somewhat, however, the agency has since withdrawn the article from its Web site.

Tip: To improve documentation when the requesting physician does not provide a written request, make up your own consultation form. For instance, when you receive the phone call from Dr. X's office, you can fax back a form for Dr. X to sign requesting the consult. Although not required, this step will give you extra protection.