Orthopedic Coding Alert

Difficulty differentiating between consults and referrals could cause trouble When you code consults, the devil is in the details: The request for your orthopedist's opinion, his documentation, and his report back to the requesting physician must align correctly with CMS or CPT guidelines, or else his hard work will earn your practice nothing.
 
If your practice performs consults, you should know what to look for in your physician's documentation and what codes you should use when your physician performs a consult or referral. Know Your Codes CPT includes four types of consultation codes:
  Office or other outpatient (99241-99245)
  Initial inpatient (99251-99255)
  Follow-up inpatient (99261-99263)
  Confirmatory (99271-99275). 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 [...]