Ob-Gyn Coding Alert

For referrals in the office setting, you should use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient), says Kristine Eckis, CMM, CPC, president of The Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. In such a case, the specialist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment or follow-up care.

What's in a Name: Defining Consults and Referrals

"A consult is a service rendered to give an opinion to a requesting physician about a patient's condition," Eckis says.
 
For example, a 22-year-old woman with severe cramping and pain during sex reports to her internist. The internist performs an abdominal ultrasound, is unable to diagnose the patient and sends her to an ob-gyn for a consultation. The internist contacts the ob-gyn to explain the patient's condition and then sends a written request for the gynecologist's opinion. The ob-gyn performs a pelvic exam, discusses the patient's symptoms and the duration and frequency of the pain, and develops a possible treatment plan for endometriosis. The ob-gyn then reports her findings back to the internist.
 
The ob-gyn's service is an office consultation, and you would code it using the appropriate code from the 99241-99245 range.
 
"A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another," Eckis says.
 
For example, a 65-year-old postmenopausal woman reports to her primary-care physician (PCP) complaining of intermittent vaginal bleeding. The PCP refers her to an ob-gyn. The ob-gyn sees the new patient, adjusts her hormone levels, and schedules a follow-up visit for the following month. You should code the ob-gyn's service using a new patient office visit code (99201-99205).
 
The intent of the visit is key for defining consultations, says Jennifer Swindle, RHIT, CCS-P, CPC, CCP, coding reimbursement services supervisor for a multispecialty 150-physician clinic in Lafayette, Ind. "The physician who requests the consult is seeking the evaluation and opinion of another," she says. "The consultant may or may not provide treatment at this visit, but the intent of the visit was for his or her opinion."
 
Swindle finds thinking of consults as a "circle" of care helpful. The requesting physician sends the patient to the specialist, and the specialist provides an evaluation and opinion and, at the conclusion of the consultation, sends the patient back to the requesting physician. The specialist also sends to the requesting physician a written report of his or her findings and any treatment that may have been rendered. If the specialist takes over the patient's care, however, the circle is broken.
 
When a PCP sends the patient to an ob-gyn with the intention that she will assume treatment for the patient, this is a referral or transfer of care. In this case, the ob-gyn treats and then follows up with the patient for the care of her condition.
 
Billing for a consultation code when the service provided doesn't meet the definition of a consult can land a practice in hot water with the Office of Inspector General and with the state attorney general - not to mention invite an audit.

Documentation Is Vital ... Be Careful Using 'Refer'

Ob-gyns must pay particular attention to their documentation - whether they are requesting or delivering a consultation - to provide an accurate record of the patient's treatment.
 
Always make sure the physician documents the request for a consultation in the patient's record, whether the initial request is verbal or written. Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the physician's office and the specialist's office.
 
The request's wording is important. Physicians should avoid using the word "referral" when they are actually requesting a consultation. Using this word can imply a transfer of care and be a red flag to auditors. Eckis advises using the term "consult" in the request, a tactic that makes the nature of the visit very clear should the information every be audited.
 
Physicians reporting back to the requesting physician following a consultation should be equally careful with "refer," she adds. "In many cases, physicians will write a note stating, 'Thank you for referring Anne Smith to me ...' This is fine for referrals. But for consults, more appropriate wording would be, 'Thank you for your request to render a consultation ...' "
 
This can also mean trouble for the specialist in the event of a postpayment audit. In the above example, a physician asked a specialist for a consult. The specialist completed the consult, fulfilling the requirements of the service, including sending the report to the requesting physician. In the course of evaluating the patient, the specialist decided that he should follow the patient's care for the particular problem. However, in his note to the original physician, he thanks the pediatrician for referring the patient to him, when he had, in fact, delivered a consult.
 
In an audit, a carrier might consider the initial code for a consultation inaccurate, due to the slip in semantics. "It sounds as though the requesting physician sent the patient over to the specialist, expecting the specialist to assume care," she says. If that were the case, a consult code would not be valid.

'Request' Rules Differ for Confirmatory Consults

According to CPT, you should report "A 'consultation' initiated by a patient and/or family, and not requested by a physician" using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient). In addition, you can code for these consults when an insurer or third party seeks a second or third opinion.
 
CPT designates that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."
 
You can use 99271-99275 with new or established patients when the patient wants a second opinion and when an insurer requests a specialist's opinion. The ob-gyn can provide confirmatory consults in any setting. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code and append modifier -32 (Mandated services).