Orthopedic Coding Alert

What's in a Name: Defining Consults and Referrals

When another practitioner requests your orthopedic surgeon's opinion about a patient's condition, you should report a consult code.
 
Example: A patient presents to her primary-care physician (PCP) complaining of shoulder pain. The PCP cannot establish a diagnosis and asks an orthopedic surgeon to evaluate the patient and give his opinion regarding the patient's condition and possible treatment methods. The orthopedic surgeon examines the patient, determines that she has a torn rotator cuff (840.4), and recommends arthroscopic repair (29827, Arthroscopy, shoulder, surgical; with rotator cuff repair). He sends the PCP a report with his diagnosis and his recommendation.
 The orthopedist's service qualifies as an office consultation, and you should report the appropriate code from the 99241-99245 range.
 
Referrals: No request, no report. A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.
 
Example: A 23-year-old woman with severe knee pain reports to her internist. The internist orders an MRI, and the radiology report indicates that the patient has a torn medial meniscus (836.0). The internist refers the patient to the orthopedic surgeon for surgical repair. Because the internist does not ask the orthopedist to render an opinion on the patient's condition, the orthopedic surgeon should code his service with a new patient office visit code (99201-99205).
 
"Doctors frequently say to patients things like, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," Hammer says.  The bottom line? Don't report a consult unless another physi-cian requests it and you send a report back to him.
 
Remember: Although Medicare requires you to send a written report back to the requesting physician, CPT isn't as specific. The January 2002 CPT Assistant states, "CPT nomenclature does not specify what form the communication must take. The consultant may call the requesting physician or other appropriate source on the phone to discuss his or her findings, or he or she may write a report and send it to the requestor. If the communication is verbal, the phone call and the discussion during that phone call should be documented by both the physician requesting the opinion and the consultant providing the response."
 
Billing a consultation code when the service doesn't meet the definition of a consult can land a practice in hot water with the Office of Inspector General and with the state attorney general - not to mention invite an audit. "If you report a consult without documenting the request, you're overbilling," Hammer says.

Documentation Is Vital - Be Careful Using 'Refer'

Orthopedists must pay particular attention to their documentation - whether they request or deliver a consultation - to provide an accurate record of the patient's treatment.
 
Always make sure that the orthopedist documents the request for a consultation in the patient's record, whether the initial request is verbal or written. Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the requesting physician's office and at your office.
 
When your orthopedist reports back to the requesting physician after a consult, you should avoid the word "refer." Instead of saying, "Thank you for referring John Doe to me ...," the orthopedist should write, "Thank you for your request to render a consultation ..."

Consult With Treatment? Append -25

Orthopedic coders often face denials when the surgeon performs a consult and provides treatment on the same day, but you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for these services and fight denials when necessary. Consider the following scenario that a subscriber submitted:
 
An internal-medicine physician asks the orthopedist to consult on a patient with shoulder pain. The orthopedist determines that the patient has an impingement syndrome of the shoulder and administers a cortisone injection. The insurer rejects the injection charge because the payer doesn't reimburse for consult and treatment on the same date.
 
"Usually the denial happens the other way around: The consult is denied as bundled with the treatment code even when a modifier -25 is used," says Sandi Hamrick, CPC, coder at Toledo Orthopaedic Surgeons in Ohio. "It sounds like this particular insurer is not following CPT guidelines, which most certainly allow for a consult and treatment to be billed, but is instead following its own rules."
 
Solution: The practice should appeal the denial with copies of documentation from CPT, Hamrick says. CPT states that you should separately report any specifically identifiable procedure (identified with a specific CPT code) performed on or subsequent to the date of the
initial consultation.

'Request' Rules Differ for Confirmatory Consults

According to CPT, you should report "A 'consultation' initiated by a patient and/or family, and not requested by a physician" using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient). In addition, you can code for these consults when an insurer or third party seeks a second or third opinion.
 
CPT says that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."
 
New/established: Doesn't matter. You can use 99271-99275 for new or established patients when the patient wants a second opinion and when an insurer requests a specialist's opinion. The orthopedist can provide confirmatory consults in any setting. If an insurer requires the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code and append modifier -32 (Mandated services).