Ophthalmology and Optometry Coding Alert

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 you need to clarify the office visit.

CMS Partially Lets Consultants off the Hook

The ensuing paperwork trail led CMS to reconsider the feasibility of making the consultant responsible for the requesting physician's documentation. "On April 12, 2006, the PRIT (Physician Regulatory Issues Team) released a statement stating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient's chart," writes Diane Daigle, president of Maine Medical Group Management Association. When an appropriate source requests a consult, the consultant isn't responsible for making sure the requesting physician's files include that request in writing.

That's not all: CMS officials still insist that the requesting physician document the request for a consult. The only change is that the consultant doesn't have to verify that the requesting physician has done so.

So what will happen if a carrier audits the consultant and doesn't find any request documented in the requesting physician's files? Will the consultant still get paid? At this point, CMS hasn't been able to answer that question.

"It is a real paper chase for the consultant to have to look at the requesting physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif.

The issue isn't resolved: The PRIT has also been asked by the Indiana State Medical Association to clarify the definition of "transfer of care," as it relates to Medicare Transmittal 788. According to the CMS web site, the PRIT is facilitating dialog between CMS staff, providers, and carrier staff to clarify this definition. Also, the PRIT is working with the Infectious Disease Society of America, the American College of Physicians, the American Medical Association and several other specialty societies to clarify the definition of a consult, as it relates to Medicare Transmittal 788.

Best advice: As always, you should let documentation guide your coding. Now more than ever before, the consultant must have a reason and request for the consult documented in the patient's medical record, along with an opinion rendered by the consulting physician, with a written report sent to the requesting physician.

Look for Complete Circle of Care

Experts also recommend adding the "fifth R" of returning (or discharging) the patient back to the requesting physician when the episode of care is complete.

Remember: The "return" does not always occur at the end of the consultative service. "The consultant is permitted to initiate treatment, when appropriate, and still report a consultation," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at  the University of Pennsylvania department of medicine in Philadelphia.

When the consultant completes the course of treatment, eventually discharging the patient from his care, a notation in the medical record helps distinguish between ongoing care and future consultation requests, Pohlig says.

Refer to the New Consultation 5 R's

Keep the consultation requirements straight with these basics. The five R's of a consultation are:

• Reason: Both the requesting and consulting physicians must document a medically necessary reason and request for a consultation. But the consultant doesn't have to verify that the requesting physician did so. However, in the hospital setting where the medical record is shared, it is a good idea to verify a request for consultation versus a request for medical management, which is not a consultation (e.g., diabetic management, anti-coagulant management, etc.).

• Request: The request must come from another physician or qualified NPP. CPT also allows requests from other appropriate sources, so check with your payers to determine what they consider valid consult request sources.

• Review and Render: The consultant must review medical records that may have been provided by the requesting physician and then render the history, exam and findings. The consulting physician may initiate diagnostic and/or therapeutic services.

• Recommendations and Report: The consultant must issue a separate written report of his findings and recommendations for treatment to the requesting source. If the consulting physician initiates treatment, experts suggest you use the words "I have taken the liberty to begin treatment" in the report.

• Return (recommended by experts): To further show that a transfer of care didn't initially occur prior to the consultation request, the consultant should send the patient back to the referring physician after treatment has ended.

Example: A patient complains of a red, irritated, painful eye, which his primary-care physician treats with antibiotics. Several days after treatment, the patient's eye continues to exhibit the same symptoms and appears to worsen (reason). The PCP requests a consultation for evaluation of the patient's eye and treatment recommendations from an ophthalmologist.

Your ophthalmologist reviews the previous medical records and examines the patient. After finding a small foreign body, the ophthalmologist removes it, prescribes antibiotic drops, bandages the eye and advises the patient to follow up with his PCP (return). Your ophthalmologist sends a report of the consultative encounter to the PCP with his findings and recommendations for further care.