Fight Back Against Consult Denials by Proving 5 R's
Published on Mon Mar 05, 2007
Not documenting the request could land you in hot water You can probably recite the three "R's" of consultation coding in your sleep: request, render, and report. For 2007, you need to alter your mantra to include two more "R" requirements -- a reason and a return of care. And without those, you won't be able to successfully report a consultation.
Reality check: The old-school three R's have shifted. In 2006, CMS issued two statements increasing the documentation requirements for consultations.
Important: These are Medicare guidelines only, but they are generally accepted by private payers. Check with your individual payers to ensure you're following their consultation requirements. Reacquaint Yourself With the 3 R's Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:
• request for opinion
• rendering of services
• report to the requesting source. First on Medicare's chopping block were qualifying requesters. The new CMS guidelines require a physician or qualified nonphysician practitioner (NPP) to make the request. CPT specifies, however, that the request can be from a physician or other appropriate source.
Note: Medicare limits the definition for the NPP category of provider to a nurse practitioner, physician assistant, clinical nurse specialist or certified nurse midwife.
Protect Yourself With Written Reason and Request In December 2005, CMS added reason to the consultation R's. Transmittal 788 requires that the requesting physician or NPP document the request and the reason for a consult in the patient's medical record. This advice existed as spoken instruction, but it had never before been given in writing, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.
Helpful tool: To help ensure that requesting physicians meet the new requirement, Cobuzzi suggests creating a reverse request fax consultation form. Consultants can fax the form to the requesting physician to be filed in the patient's chart. "We can't make [the requesting source] file the form, but using the tool at least increases the chances that there is something in the chart," Cobuzzi says.
However, asking the requesting physician to fill out a form, fax it back to the consulting physician's office and also file a copy in the patient medical record can be a burdensome task for the requesting physician's office.
Another less burdensome suggestion is to ask the patient to bring a copy of his medical records from the requesting physician's office with him on the day of the appointment. This not only allows the consulting physician to review the workup already performed by the requesting physician but also verifies whether a request for consultation has actually been documented in the medical record. If no request is documented, a simple phone call to the requesting physician's office may be all [...]
