Ob-Gyn Coding Alert

Difficulty differentiating consults and referrals won't just land you in a heap of denials. It could be the source of unwanted scrutiny from the feds.
 
When coding referrals and consults, the devil is in the details: How the request is worded, documented and reported must align correctly with CMS guidelines, or else your hard work will earn you nothing. Understand both sides of the equation - what to look for in physician documentation and what codes to use when a consult or referral is delivered - to provide a great service for your practice and your colleagues' practices: clean billing. Know Your Codes  CPT includes four types of consultations:
  office or other outpatient (99241-99245)
  initial inpatient (99251-99255)
  follow-up inpatient (99261-99263)
  confirmatory (99271-99275). 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 [...]