Ophthalmology and Optometry Coding Alert

Caution: Avoid adding a consultation to every surgical procedure.

When a primary care physician requests your ophthalmologists opinion, advice, and recommendations for treatment of a patient, consultation coding is a challenge even for veteran coders. The most important questions you must ask before ever assigning a consultation code are:

" Does the encounter meet the definition of a consultation?

" Is the intent clearly a request for recommendations on a treatment plan?

You must also understand what constitutes a transfer of care or request for management of a patients condition.

In the event the request meets the consultation definition and intent, know the six Rs to document a true consultation.

Question 1:What are the required components for coding a consult?

When you submit a claim for an appropriate consultation, you should be sure your providers documentation supports the consultation circumstances. Documentation requirements for consultations vary by payer, but experts say your consultation documentation should at least include evidence of:

" The name of the Requesting provider

" The Reason for the consultation (& evaluation and recommendation of ...)

" A Review of any records sent by the requesting provider

" Documentation of the consulting providers Rendered history and examination

" Documentation of the consulting providers impression and Recommendations for treatment

" A separate written Report to the requesting provider.

Important: The request for consultation does not need to be in writing, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. However, the consulting ophthalmologist should document the request as part of the patient/provider encounter.

Your documentation should support the six Rs whether youre reporting an outpatient (99241-99245, Office consultation for a new or established patient &) or inpatient (99251-99255, Inpatient consultation for a new or established patient &) consultation. The only exception is that there is no need to provide a separate written report to the requesting provider when the medical record is shared, Mac says. A shared medical record may be the case in the hospital setting or in a multispecialty clinic where the medical record is a shared paper chart or electronically stored patient chart.

Helpful: The Department of Health and Human Services Office of Inspector General (OIG) found that 75 percent of all consults billed in 2001 had coding or documentation problems. Problem areas include level-three consults billed as level-five consults, bad documentation, and office visits billed as consults.

You can read the OIG report at  www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf.

Question 2: How important is a documented request?

The reason for a consultation must be documented, Mac says. Medicare expects that the requesting provider will document the request in the patients medical record.However, it is not the responsibility of the consulting provider to obtain the documentation from the requesting provider in order to report a consultation.

Medicares Physicians Regulatory Issues Team (PRIT) addressed this issue in 2006. Medicare does not expect the consulting physician to verify that the requesting physician has documented the consultation request in his/her patients medical record, stated PRIT on the CMS Web site.

Instead, the consulting provider should document the name of the requesting provider and reason for consultation to fulfill this requirement, Mac advises.

Question 3:What do payers consider a transfer of care?

This question of transfer of care often trips up coders. During a consultation, your consulting surgeon is allowed to perform diagnostic testing or even initiate treatment. However, he must return the patient to therequesting physician for ongoing care.

Key: If the intent of the requesting physician was for the surgeon to manage the care of the patients condition, there is no consultation, Mac warns. It is, therefore,extremely important to understand the intent of the requesting providers request for the ophthalmologist to see a patient.

Remember this fact: 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.

If a consulting provider has started treatment, he should also document in the medical record or separate report to the requesting provider, I have taken the liberty to begin treatment.

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.

Question 4: Does every surgery involve an inpatient consultation?

Another surgeon may request a consultation from your ophthalmologist prior to performing surgery on a patient. The visit must still meet all the requirements of a consultation, however, says Tina Landskroener, CPC, CCS-P, PCS, business office manager for Blessing PhysicianServices in Quincy, Ill. Keep in mind that the request should not simply be for a routine screening such as glaucoma screening.

You should only bill for a consultation if the primary physician caring for the patient requested a consultation from your ophthalmologist. In other words, only bill a consultation if the primary physician requested your doctors opinion or advice for a treatment plan for a specific condition or surgical clearance for a specific condition.

If your ophthalmologist was called in just to perform a surgery, and there was no request for an opinion or recommendation, then you cannot bill a consult. But keep in mind that a consultation can lead to treatment once the ophthalmologist completes the patient workup.

You would bill a consultation only if the primary doc requested of your doc an opinion and/or recommendation on a specific condition, confirms Tracy Helget, CPC, billing office supervisor for Medical Associates of Manhattan PA in Manhattan, Kan. If your doc was requested to perform a surgery, there was no request for an opinion or recommendation, therefore no consultation.

It all depends on the intent of your providers involvement in the patients care, which should be reflected in the medical record documentation, Mac notes.

Note: A separate report sent to the requesting physician is not required when the requesting physician and consultant share a common medical record (which is usually the case in the inpatient setting).

If the service does qualify for a consultation code assignment, bill an inpatient consultation using the appropriate level supported by the documentation from 99251-99255 (Inpatient consultation for a new or established patient &).