Ob-Gyn Coding Alert

Improper coding of consultations and referrals can lead to two major problems:

1. Practices that miss opportunities to code legitimately for consultations lose precious reimbursement dollars by not coding to a high enough level, and

2. Practices that improperly code for consultations when a lesser code is correct run the risk of both an audit and fraud allegations.

Curtis Udell, CPAR, CPC, president of Emphysys, a medical coding consulting company in Cumming, Ga., says that consultation coding is a critical issue for ob/gyns in particular because they treat or refer patients for a variety of specialized problems, like infertility, high-risk pregnancy or ill-defined conditions.

CPT 2001 and HCFA each devote much space to defining consultations. HCFAs rules are contained in the Medicare Carriers Manual (MCM) Part 3, Chapter XV Fee Schedule for Physicians Service, section 15506, Consultations.

CPT defines a consultation as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

CPT also presents four categories of consultations: 99241-99245 for outpatient consultations, 99251-99255 for inpatient consultations, 99261-99263 for followup inpatient consultations and 99271-99275 for confirmatory consultations.

Clinical Scenarios

The following clinical scenarios are specific to ob/gyn and identify what type (if any) of consultation should be coded:

Scenario #1: A 54-year-old postmenopausal woman reports to her primary care physician (PCP) with complaints of vaginal bleeding. The PCP refers her to her ob/gyn. The ob/gyn sees this established patient, adjusts her estrogen prescription and plans an endometrial biopsy the following week.

The correct code: The ob/gyn should code the visit 9921x for an established patient office visit.

The reason: The patient is being referred to her ob/gyn for the treatment of a specific problem. The ob/gyn is not being asked for an opinion; rather it is assumed she will manage the care of the womans problem.

Scenario #2: A 23-year-old indigent woman reports to the emergency department (ED) with severe cramping and bleeding. The ED physician examines her, orders an ultrasound and contacts the ob/gyn on call. The ob/gyn views the ultrasound film, which shows an ectopic pregnancy. He admits the patient, performs a D&C (dilation and curettage) and assumes followup care until her release.

The correct code: The initial visit in the ED by the ob/gyn on call is coded 9925x-57 for initial consultation of a new or established patient and for decision for surgery. Use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) instead of modifier -57 if the payer requires it.

The reason: The E/M service was a consultation that ended in the inpatient hospital setting. Although the service began in the ED (usually considered an outpatient service), the physician bills the most extensive service for the day. The -57 or -25 modifier is required because this was the consultation at which the decision to do surgery was made. The difference is that -57 is normally added when the decision is made to perform major surgery on the same day as the E/M service, and the -25 modifier is usually added when the decision is made to perform minor surgery on the same day. The care subsequent to the consultation will become part of the global surgery care.

Scenario #3: A 36-year-old pregnant woman has an amniocentesis at her ob/gyns office. The amnio indicates severe fetal abnormalities, and the ob/gyn recommends terminating the 22-week pregnancy. Before having the abortion, the woman and her husband see a specialist in maternal fetal medicine (MFM), who confirms the ob/gyns findings. They return to their ob/gyn and the pregnancy is terminated.

The correct code: The one-time visit to the MFM can be coded as a 9927x (confirmatory consultation for a new or established patient ...) because the patient initiated the visit for a second opinion. If the MFM provided only a review of the patients records and tests, however, the correct code would be 9920x (office or other outpatient visit for the evaluation and management of a new patient ) with the level selected based on documented face-to-face counseling time.

The reason: CPT specifically states that a consultation initiated by a patient and/or family, and not requested by a physician is not reported using the initial consultation codes but may be reported using the codes for confirmatory consultation or office visits, as appropriate. The confirmatory consultation codes require history, an examination and medical decision-making. No typical time is included in the code definition.

Scenario #4: A solo ob/gyn has a 42-year-old established diabetic patient whom he routinely treats for gyn care. When she becomes pregnant for the first time, he refers her to a perinatologist for the duration of her pregnancy. The ob/gyn makes himself available to the perinatologist should further input be needed as the pregnancy progresses, and he arranges to handle delivery with the perinatologist standing by.

The correct code: Visits with the perinatologist are coded using either 59425 (4-6 antepartum visits) or 59426 (7 or more antepartum visits) and 59430 (postpartum care only) because the perinatologist will only be billing for the antepartum and postpartum care. Delivery of the fetus by the ob/gyn is coded 59409 (vaginal delivery only) or 59514 (cesarean delivery only), depending on the method.

The reason: When the ob/gyn referred the patient to the perinatologist, he did so knowing that the specialist would assume care for the duration of the pregnancy. Therefore, the first visit with the perinatologist was not a consultation, but rather an initial ob visit. The perinatologist bills for the number of antepartum visits using the appropriate code and will also bill separately for the postpartum care.

Scenario #5: A 65-year-old woman reports to her gynecologist with symptoms of pelvic pain and swelling. The gyn orders an ultrasound, which indicates a mass. Suspecting a malignancy, the gynecologist sends her to a gynecologic oncologist, who performs a biopsy on the woman and confirms a malignant ovarian tumor. The gyn-oncologist begins an aggressive treatment plan including surgery, radiation and chemotherapy and treats the woman for eight months, until she is diagnosed as cancer-free.

The correct code: The initial visit to the oncologist is coded 99245 (office consultation for a new or established patient ...). All subsequent visits to the oncologist, as well as any to the referring ob/gyn, are coded using established patient E/M codes.

The reason: As in scenario #2, the consulting physician did not assume care for the patient until he determined what was wrong with her, then he assumed care for the duration of the patients problem.

Remember the Three Rs of a Consultation

The following three requirements must be part of the patient record and claim to prove a consultation occurred:

1. Request: Another physician or other appropriate source must request a consultation. An other appropriate source is generally viewed as a professional who can act on the advice given. If the patient contacts the specialist directly, it is not a consultation unless a second opinion is sought, as in scenario #3, in which case the confirmatory consultation codes (99271-99275) may be used.

There must be a direct request from the attending physician to the specialist documented in the patients medical record. Otherwise, the specialist serving as consultant is responsible for documenting the request with a note in the chart that begins, Ms. X is a 65-year-old female, seen in an oncological consultation at the request of Dr. A for evaluation of _____. Stating the reason for the visit initially with this type of note will stand up in an audit.

2. Reason: Show medical necessity in the documentation for the consultation services provided. A note in the chart should explain why the consultation was requested. For example, if the requesting ob/gyn was concerned that his ob patient was high-risk, but the perinatologist was able to rule that out, this should be well documented in the chart.

3. Response or Report: According to CPT, the consultant must furnish a written report to the requesting physician. The report should indicate findings, treatments performed and whether the consultant elects to followup with the patient. A physician generally does not remain as a consulting physician except in the rare instances when there is a further specific request from the patients attending physician to work with the PCP in treating the patient.

According to Wanda Brown, CPC, billing manager for University of Florida Jacksonville Physicians Inc., the consultation report should be a separate document communicated to the requesting physician. It is best to include verbiage such as Thank you for the opportunity to provide a consult on patient X, Brown says, rather than saying Thank you for referring patient X to me. Use of the word refer implies that the attending physician is handing over care to the consulting physician, which is not the case with initial consultations.

Remember, whether a visit is a consultation hinges on if a transfer of care was intended and occurred. In many situations, the assumption is that the ob/gyn or ob/gyn specialist will complete the care for the patients complaint, and any problem, complication or service related to treatment is the responsibility of the ob/gyn. This is particularly true in the ED, where the patient is unlikely to return to the ED physician to finish her care, but was referred to the ob/gyn with the intention of handing her over. But, if the consulting physician did not know until after seeing the patient that she or he would be assuming care, the initial visit is a legitimate consultation.

Start at the Front Desk

Udell says the first step to correct coding for consultations is to adequately train front desk staff, or whoever makes the initial appointments. When your staff take an appointment from another doctors office, he says, they should be asking pointed questions about what your office is being asked to do. Udell even recommends a script for the scheduling staff that essentially says, OK, Dr. A is sending Ms. Jones to us for opinion and advice on ... Udell also suggests that practices have a document at the front desk that defines the types of service, so staffers know what they are scheduling. Front desk staff often gets overlooked when it comes to training for documentation and coding, he says, but they are an important link in the documentation chain.