Orthopedic Coding Alert

Improperly billed consultations are high on the fraud and abuse list of the Health Care Finance Administration (HCFA) and Office of Inspector General (OIG). Auditors are checking documentation carefully to see if consults should have actually been coded as outpatient or subsequent hospital visits. And they (HCFA and OIG) have been winning a lot of money. Orthopedic practices could be a special target, because orthopedists skills are often called upon by other physicianseither to provide an option or take over the care of the patient.

Most of the time, when an orthopedist is called to the ED it should not be coded as a consult, because he or she is being called to actually fix the problem [which is actually a transfer of care], not render an opinion on how it should be fixed, says Susan Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC.

However, you dont want to automatically downcode to an outpatient code (99201-99215) or subsequent hospital visit codes, because your practice is ethically entitled to bill for true orthopedic consults. There are times when billing for a consult is legitimate.

The key to correct coding for consults is understanding the difference between a consult and transfer of care.
First, before coding a consult, coders should check the documentation and talk with the orthopedist to find out exactly what words the requesting physician used and what course of action your orthopedist took. For example, look and listen for Medicares key components of a consultation. (See insert: Medicare Carriers Manuals [MCM], Section 15506.)

Medicare Carriers Manual,Section 15507, Item G Reporting of Visits When Patient is Seen in Emergency Department and Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting If the ED physician is requesting the orthopedists opinion or advice for use in the ED physicians treatment of the patient, the specialist should bill for a consultation. If the ED physician asks the orthopedist to evaluate and treat the patient, he or she has transferred responsibility for the patients care to the specialist at the time of referral. The orthopedist should bill the appropriate visit code for the service. If this service is furnished in the ED, the other physician would bill an ED visit [99281-99285]. If the service is furnished in the orthopedists office, then he or she would bill an outpatient office visit [99201-99215].

Request for an Opinion

The patients record must contain the primary care or ED physicians request for a consultation from the orthopedist.

If the record says consult and treat or evaluate and treat, that does not equal a consultation, emphasizes Quin Buechner, MS, CPC, consultant for Webster, Rogers, Grady, Benson, King, Skipper, a healthcare accounting firm in Florence, SC. In these examples, no opinion is being asked; therefore you have to bill as a subsequent hospital visit or outpatient visit, he says.

Tip: Caution your orthopedists to use the word referral correctly, warns Buechner. Auditors, he explains, tend to assign the same meaning to referral as that of health maintenance organizations, which is actually transfer of care (i.e., a physician sends a patient to your practice with the intention that your orthopedist will assume treatment for the patient).

Therefore, instruct your orthopedists not to begin their letter of findings by saying, Thank you for referring [patients name]. Instead, he or she should dictate, Thank you for your request to render an evaluation of [patients name] for [patients condition].

Otherwise, you wave a red flag for the auditors who will wonder why you used the term referring and the service was billed as a consult rather than a transfer of care, explains Buechner.

Consult Means Telling, Not Doing

A consult means the orthopedist is asked to provide an opinion on how the primary care physician or the ED physician should care for that particular condition, not how the orthopedist himself will care for it, Stradley explains.

1. Consult Examples:

A.) If the primary care or ED physician asks an orthopedist to recommend a course of treatment that the requesting physician will continue to manage, then this is a consult.

Stradley confirms this by saying, If the requesting physician asks the orthopedist, How else can I deal with this condition in the scope of what I am doing? [with no intention of handing the patients care over to the orthopedist] and the consultant provides that information, then you can bill a consult.

B.) Nancy Bryan, office manager for Anthony E. Melonakos, MD, an orthopedic surgeon in Monroe, MI, offers this example: Suppose a patient is brought to the ED with multiple trauma. The trauma physician consults with several specialists in order to see what needs to be treated immediately. In this case, you could bill a consult because the orthopedist does not assume care of the patient; he or she is merely rendering an opinion to the trauma physician, Bryan explains.

C.) An out-of-town patient presents to the ED with an injury. The ED physician calls the orthopedist, who provides an opinion, but the patient is released and plans to be treated by his or her hometown physician. Again, care is not transferred, so the consultation can be billed, says Bryan.

2. Transfer of Care Example:

The more usual scenario happens when the patient is injured and the primary care physician or ED attending knows that he or she does not have the skills or expertise to treat the injury. In this case, he or she is actually transferring care and asking the orthopedist to take over that portion of the patients condition. In these instances, you cannot bill a consult for the orthopedist services, because it is a transfer of care.

Yet, its often billed incorrectly by orthopedists, says Todd Thomas, CPC, CCS-P, president of the Oklahoma Chapter of the American Academy of Professional Coders, who works in an ED as a coder. For example, when Thomas noticed an orthopedist dictating his services as consultations, he broached the subject immediately. I explained that our ED docs call him to take care of fractures and dislocation, not ask for an opinion; therefore he should not be billing a consult, Thomas says.

Thomas is right, confirms Stradley. If the requesting physician knows the patient has a fracture and that the only option is a reduction which must be done by an orthopedist, that is considered a transfer of care, not a consult, she explains.

But many orthopedists think the CPT says physicians can do therapeutic treatment during a consult.

Actually, both the MCM and CPT say that in the course of rendering an opinion to the requesting physician, the consulting physician may initiate therapeutic treatment, order diagnostic tests, and perform services. But the physicians only treat or test in order to reach that opinionnot to fix the problem. So, dont use this statement to justify charging a consult when you shouldnt.