Orthopedic Coding Alert

Contrary to what many coders believe, more than one physician can bill consultation codes for the same patient on the same day, even if the physicians all work for the same practice.

The key to reimbursement is ensuring that each physician manages a separate aspect of the patient's care and submits different specialized diagnoses on their consultation claims.

By now, most orthopedic coders are familiar with the three R's of consultations: The consult codes (99241-99263) can only be billed if another physician requests the orthopedist's opinion, the orthopedist performs a formal review (exam) of the patient, and the orthopedic practice sends a report back to the requesting physician. Although the three-R's rule is easy to remember and usually simple to apply, it doesn't answer every orthopedic consultation question.

Jeanne Smith, reimbursement specialist/auditor at Madrona Medical Group, a 45-physician multispecialty group in Bellingham, Wash., says many coders mistakenly believe that several physicians from the same practice can't bill consultation codes for the same patient on the same day. "Concurrent care is an area that frequently gets confusing, and coding correctly for the consultations means speedier reimbursement," Smith says. "It also means avoiding the paperwork and frustration that is created by denied or bundling claims."

Section 15506C of the Medicare Carriers Manual (MCM) states, "Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met."

Smith offers an example: "Say we had a gentleman in the hospital with a total hip replacement (V43.64) who also has COPD [chronic obstructive pulmonary disease, 496] and develops atrial fibrillation (427.31). The orthopedic surgeon requests that one of our pulmonologists consult and manage the patient's COPD and requests a consult from one of our cardiologists for the atrial fibrillation."

Both the pulmonologist and the cardiologist should submit their consultation claims using the diagnosis codes most pertinent to their care, Smith says. Because the consultations took place in the hospital, the pulmonologist would submit his or her claim using 99251-99255 with 496 as the ICD-9 code, while the cardiologist would file his or her claim using 99251-99255 with the diagnosis code 427.31.

Many orthopedic practices hesitate to bill consultation codes when a nonphysician practitioner (such as a nurse practitioner or physician assistant) requests the orthopedist's opinion. Some practices even balk at billing the consultation codes when a podiatrist or chiropractor logs the request. But all of these medical professionals are qualified to request and perform consultations.

According to Section 15506 of the MCM, "Non-physician practitioners, e.g., nurse practitioners, certified nurse-midwives or physician assistants, may request a consultation. They may also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of non-physician practitioner in the state in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules."

Fracture care accounts for an overwhelming number of referrals to orthopedic practices. Most of the time, however, these services cannot be billed as consultations because the referring physician already knows that the patient has a fractured bone and requires specialized care.

For example, says Debra Lee, coding coordinator at Orlando Orthopaedic Care in Florida, the following scenario is a referral not a consult and, therefore, should be billed using new patient E/M codes (99201-99205).

"An urgent care office sent a patient with a fracture to our office," Lee says. "The urgent care physician took an x-ray, diagnosed the fracture and noted that he was sending the patient to an orthopedic surgeon for fracture treatment. The workers' compensation insurer said they would pay our practice only for the fracture charge but not a consultation because the urgent care practice diagnosed the fracture."

According to CMS' consultation reporting standards, Lee is absolutely correct. Nonetheless, one practice maintained that it would bill this type of visit as a consultation, using the argument that "the orthopedist still has to review all of the work that the referring physician did and form an opinion from his specialized point of view, which sometimes differs from that of the referring physician. Plus, we always send a report back to the other practice, telling them the patient's outcome."

The key element missing from this practice's rationale is the request for an opinion. If the referring physician already knew that the patient had a fracture and required specialized orthopedic care, he or she did not require the orthopedist's opinion and merely transferred the patient's fracture care to the orthopedist. A transfer of care is not a consultation and should not be billed as such.

If the orthopedist performs a secondary procedure (such as an injection) during the initial consult, both the treatment and the consult can be billed as long as the three R's of the consultation are met. Section 15506B of the MCM advises that Medicare will pay for treatment and an initial consultation on the same date unless a transfer of care occurs.

The MCM states, "A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patient's condition should be reported as established patient office visit or subsequent hospital care, depending on the setting."

Because consultation coding guidelines hinge on whether a referring physician requests an opinion or transfers care, orthopedic practices should take note of how CMS perceives transfers of care.

Section 15506 B of the Medicare Carriers Manual defines a transfer of care:

"When the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. The receiving physician would report a new or established patient visit depending on the situation (a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years) and setting (e.g., office or inpatient)."