Orthopedic Coding Alert

Collect that extra $50 by applying the 5 Rs.

Beware: The feds are shining their spotlight on consult claims. Can your documentation withstand scrutiny?

Compare your consult versus referral coding practices to our experts advice to keep auditors at bay.

Remember: To report a consultation code (99241-99255), you should extend the 3 Rs into 5 Rs, says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. They are:

1 Reason for consultation

2 Request for opinion

3 Render an opinion

4 Report back of findings: Your physician must provide a written report back to the requesting physician that describes the consulting physicians findings,recommendations, etc.

5 Return: Discharge patient back to requesting physician.

What to Do When a Request Comes In

When a doctor or NPP sends your orthopod a patient,you have to determine what the outside provider is asking for. Does she want your orthopedist to advise her in the patients treatment? Is she transferring the patient to your office to take over care? Or does she simply want your doctor to treat the patient?

Remember: A consult is a request for an opinion with the expected return of the patient for care -- and not an assumption of care by the receiving physician, says Marlene Gould, CPC, office manager/biller/coder for Verity Orthopedics and Spine Surgery, LLC, in Orlando, Fla.

If the requesting physician says to your orthopod,You have expertise in this area, and I need your opinion on how to proceed with this patient who has this chief complaint, and documents that reason in the patients chart, that meets the first requirement. In a consultation, the requesting physician lends the patient to the consultant for a specific problem and asks for an opinion.

The best way to back up the request for a consult is to have something in writing in your patients chart indicating that a physician has requested your opinion, and the problem the physician has requested your opinion on,says Michelle Allen-May, RHIT, CPC, CGSC, coder II at West Florida Medical Center Clinic in Pensacola. The main thing Medicare auditors are looking for in consults is whether there is a request for an opinion or a transfer of care between physicians.

The consulting physician may order or perform diagnostic testing, start treating the patient during the consultation visit, or assume care of the patients problem in a subsequent visit (a transfer of care). Whether or not your physician treats the patient, if the initial visit is to provide the requesting physician with a specialists advice on how to treat his patient, you can consider that visit a consultation.

Make This Referral Distinction

A referral, on the other hand, assumes that a physician is handing the patient off to your physician to take over care (which would also qualify as a transfer of care). The first physician is not requesting your orthopods opinion or advice, and there is no requirement that your doctor share his findings or plans for treating the patient with the referring physician. Thats true even if your doctor does share his findings in the name of good physician relations. Just because the second physician sends the first a letter with findings, its not necessarily a consultation, says Susan Posten, CPC, senior certified coding specialist at the University of Texass Health Science Center in Houston.

To report an E/M visit for a transferred patient, you use the appropriate level initial or subsequent inpatient/new or established outpatient visit code depending on the place of service (99201-99215, 99231-99233).

Try Your Hand at These Examples

Example 1: An urgent care office sends a patient with a fracture to your orthopedic practice. The urgent care physician took an x-ray, diagnosed the fracture and noted he was sending the patient to an orthopedic surgeon for fracture treatment.

Solution: Because the urgent care physician diagnosed the fracture and sent the patient to your orthopedist for the managed care, you should report only the fracture charge -- not the consultation (99241-99255).

Example 2: A patient in the hospital undergoes a total hip replacement (V43.64, Organ or tissue replaced by other means; hip). The patient also has chronic obstructive pulmonary disease (496, Chronic airway obstruction, not elsewhere classified) and develops atrial fibrillation (427.31, Atrial fibrillation). The orthopedic surgeon requests a pulmonologist look at the patients COPD and requests that a cardiologist look at the atrial fibrillations.

Solution: In this latter scenario, if the documentation shows a reason for the consultation, a request for advice from your orthopedic surgeon, and a reply from the second physician, the visit would qualify as a consultation. Both the pulmonologist and the cardiologist should submit their consultation claims using the diagnosis codes most pertinent to their care. Your orthopedic surgeon would continue caring for the patient.

Note: 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.