Orthopedic Coding Alert

Mastering consult coding guidelines is hard enough. Applying them in the real world of orthopedics -- when the orthopedic surgeon initiates diagnostic and therapeutic services, too -- can give you a world-class headache. Shore up your consult coding confidence with these expert insights into when you can code a consult.

"Consultation services have always been a -hot- topic as there are many interpretations of what constitutes a consult," says Quita W. Edwards, CCS-P, CPC-Ortho, CPC-I, with C.A.S.E. Contracting Services in Fort Valley, Ga. CPT and CMS have "a wealth of information available to assist in the decision-making process," she adds.

CPT rule: "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit," state CPT's consultation guidelines.

CMS rule: "A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit," according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.B.

Medicare will pay for a consult unless a transfer of care occurs, meaning a qualified provider asks the surgeon to "take over the responsibility for managing the patients- complete care for the condition and does not expect to continue treating or caring for the patient for that condition." If a transfer of care occurs, you should report a new or established patient visit rather than a consult (99241-99255) (http://www.cms.hhs.gov/Manuals/downloads/clm104c12.pdf).

Consult tip: Before you can decide whether to report a consult on the same date as diagnostic or therapeutic services, you must determine whether the surgeon provided a consult. See "Don't Code Another Consult Until You Learn These Rules" on page 121 for more information on consult requirements.

One key element of consult coding is documentation showing a qualified provider asked your surgeon for advice and did not transfer care, so you should be on alert for these situations.

You shouldn't assume certain situations always result in a consult, but you should consider whether your surgeon's documentation supports coding a consult with other services when a physician requests your surgeon see a patient with an orthopedic problem that ends up not requiring an orthopedic surgeon's expertise for treatment, says Leslie Follebout, CPC-Ortho, PCS, coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md., and senior orthopedic coder and auditor for The Coding Network.

Example: Follebout offers this scenario: A school-age child who sprained her ankle during softball season is now having recurrent problems during field hockey practice. Her pediatrician requests the orthopedic surgeon's advice on whether she requires surgery at this point, or if not, what the orthopedic surgeon would recommend for treatment.

She comes in for a consult, and the orthopedic surgeon orders an MRI and also physical therapy. The surgeon then requests the patient return for a follow-up appointment and reports back with his separate report to the pediatrician of his findings and recommendations.

In this case, the pediatrician clearly was not transferring care. He simply was requesting the orthopedist's opinion. Depending on the documentation, you may be able to report both a consult (99241-99245) and the MRI interpretation (modifier 26, Professional component, appended to a code from range 73721-73723, Magnetic resonance [e.g., proton] imaging, any joint of lower extremity -).

When a patient arrives in the emergency department (ED) with a musculoskeletal injury, the ED physician may call on your surgeon either for treatment or for advice which may or may not result in the surgeon offering treatment.

Consult: CPT Assistant (August 2001) offers the following example of when you may report a code from 99241-99245, illustrating that you may report a consult when the surgeon assumes responsibility for care at the time of (not prior to) consultation.

Example: "A 10-year-old patient presents to the emergency department with a fractured distal radius. The ED physician decides to request an orthopaedic consultation because of the location and nature of the fracture. The orthopaedic physician evaluates the patient in the ED and then confers with the ED physician. The ED physician then transfers definitive care to the orthopaedic physician who applies a splint."

Not a consult: Note how the CPT Assistant example above differs from the following CMS example of when not to report a consult.

Example: "The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code" (Medicare Claims Processing Manual, Chapter 12, Section 30.6.10.I).

When the ED physician calls on the surgeon to treat the patient -- not to give an opinion -- it "is not a consult because the ED physician does not intend to see the patient or manage the patient in any way once he leaves the ED," says Edwards.

The ED physician is not expecting a report, plan or recommendation from the orthopedic surgeon, she says.

Once you-ve determined that you should report a consult with testing and treatment, you need to be sure you append the proper modifier to the consult code.

If the orthopedic surgeon evaluates the patient and provides an injection, aspiration, or other minor procedure on the same date, be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code, says Edwards.

As with any time you report a procedure and E/M together, you want to be sure the consult documentation shows it was a significant, separately identifiable service, says Edwards.

You also may see consults for trauma patients, such as when the ED physician transfers care to an internist who requests the orthopedic surgeon's opinion, says Edwards. When you-re dealing with a consult and a major procedure (one with a 90-day global period), you should append modifier 57 (Decision for surgery) rather than modifier 25 to the consult code.