Optometry Coding & Billing Alert

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


New Jersey Subscriber

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

The change: Medicare recently stipulated that a consultation also requires documentation in the requesting provider'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 provider 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 provider.

To protect your consultation payments, create a form that you can fax to the requesting provider for him to file in the patient's chart.

Taking this step can't ensure that the requesting provider 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 optometrist requests a consult. Download the Medicare consultation service instructions from www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.