Ophthalmology and Optometry Coding Alert

Question: To use a consultation code, a coworker thinks we should make sure the requesting physician also documented his request. Is this a consultation requirement?


New Jersey Subscriber
 

Answer: Coding experts have always suggested that the requesting physician's chart should document the request for consultation. But no formal policy had made this a consultation requirement until now.

The change: Medicare recently stipulated that a consultation also requires documentation in the requesting physician's chart. Originally, CMS stated that the consultant had to document in the patient's medical record the "request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service)."

But Medlearn Matters article 4215 also adds that this documentation must be "included in the requesting physician or qualified NPP's plan of care in the patient's medical record."

The impact: Although not required in CPT, anticipate that private payers may adopt Medicare's new requirement and expect a properly documented request to include substantiation by the requesting physician.

To protect your consultation payments, create a form that you can fax to the requesting physician for him to file in the patient's chart. Taking this step can't ensure that the requesting physician will file the paperwork, but it increases the chances that documentation appears in the chart. Expect to see similar forms sent to you when the ophthalmologist requests a consult.

Download the Medicare consultation service instructions from www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, CPC, president of Practice Solutions, Santa Barbara, Calif.