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, [...]