Orthopedic Coding Alert

Requests for consultations are not unusual in orthopedics, nor are problems getting paid for consultations. Physicians seeking reimbursement for an evaluation and management (E/M) consultation have to convince insurance companies that a consultation actually occurred. And when treatment is rendered at the time of consultation, the reimbursement headache can get even more intense. But a clear understanding of what qualifies as a consultation, and how to document that an actual consultation occurred will ease the path to payment.

Coders two main sources of information and guidelines, CPT 2000 and the Health Care Financing Administration (HCFA), define consultations as follows:

CPT A consultation is an evaluation and management service provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or other appropriate source.

HCFA A consultation is a professional service furnished to a patient by a second physician at the request of the attending physician.

Three Elements of a Consultation

The following three requirements must be part of the patient record and claim to prove a consultation occurred:

1. Request: Another physician or other appropriate source must request a consultation. An other appropriate source generally is viewed as a professional who can act on the advice given. If the patient contacts the specialist directly, it is not a consultation (unless a second opinion is being sought, in which case the confirmatory consultation codes 99271-99275 [confirmatory consultation for a new or established patient] are used). There must be a direct request from the attending physician to the orthopedic specialist. This request must be documented in the patients medical record. Otherwise, the orthopedist serving as consultant is responsible for documenting the request with a note in the chart that begins, Mr. X is a 56-y/o male, seen in orthopedic consultation at the request of Dr. A. for evaluation of _____.

Thats the clearest documentation you can hope for, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J., where she works with 11 physicians at three locations, representing various orthopedic specialties. Stating the reason for the visit initially with this type of note will stand up in an audit.

2. Reason: Medical necessity must be shown in the documentation for the consultation services provided. A note in the chart should explain why the consultation was requested. For example, if the requesting physician was concerned that an open, rather than closed, reduction might be necessary for a fracture, but the orthopedist was able to rule that out, this should be well documented in the chart.

3. Response: According to CPT, the consultant must furnish a written report to the requesting physician. The report should indicate findings, treatments performed and if the consultant elects to follow up with the patient. A physician generally does not remain as a consulting physician except in the rare instances when there is a further specific request from the patients primary-care physician (PCP) to work with the PCP in treating the patient. Otherwise, as per CPT, If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patients condition(s), the follow-up consultation codes should not be used.

Coding When Care is Given

Getting paid for consultations once the consulting orthopedist has rendered care can be problematic. Adjusters may look at a claim that includes both consult codes and procedural codes and automatically reject the consult code. In CPT 2000, the American Medical Association (AMA) made it a little easier for consultants to render treatment by amending the instructional notes for the consultation codes, stating that a physician consultant could initiate diagnostic and/or therapeutic services at the same or subsequent visit.

This new language allowed consultants to order diagnostic testing or initiate treatment. Yet many insurance carriers still deny payment for a consultation when a procedure is performed during the same patient encounter.

We have a situation in our office where the treatment is being denied at the time of a consultation, says Kerstin Conner, a billing specialist for Ohio Foot and Ankle Inc., a two-location practice with five orthopedic surgeons located in Columbus, Ohio. Conner explains that a patient was seen at the request of another physician from an outside facility. The consulting physician examined the patient, debrided infected skin (a skin ulcer) and gave him an injection of Celestone. Conners claim to the insurance company read as follows:

99243 office consultation for a new or established
patient, which requires these three key components: a
detailed history, detailed examination and medical
decision-making of low complexity

11000 debridement of extensive eczematous or
infected skin; up to 10 percent of body surface

J0702 injection, betamethasone acetate and
betamethasone sodium phosphate, per 3 mg

20600* arthrocentesis, aspiration and/or injection;
small joint, bursa or ganglion cyst (e.g., fingers, toes)

The insurance company rejected 11000, J0702 and 20600* because it does not reimburse for consultation and treatment on the same day, says Conner. But Conner correctly cites the CPT explanation of consultations, which says a physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.

Stout explains that although the consulting orthopedist can treat a patient, as Conner found out, reimbursement gets confusing once treatment is rendered. In fact, Conners situation is common. The key to adequate documentation is for the orthopedist to stay in communication with the requesting physician via a written report so your practice fulfills the CPT requirements for the consultation.

If an orthopedist is asked to consult on a patient with shoulder pain and the orthopedist determines they have an impingement syndrome of the shoulder (726.2, other affections of shoulder region, not otherwise classified), the patient would typically be offered a cortisone injection, says Stout. The consultation and injection are billable if the orthopedist sends a written report documenting the request for the consultation and his opinion and services performed to the requesting physician. Stout agrees that the orthopedist will probably want to see the patient for a follow-up visit. At that point, the orthopedist has clearly assumed responsibility for managing the patients condition, and consultation codes no longer apply.

To resolve a problem like Conners, one method of proving the consultation took place is first to make the phone call to the requesting physician and discuss treatment before it is administered. Second, this phone call should be documented in the patients chart. Third, modifier -25 should be appended to consult code 99243 to indicate that a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service accompanied the debridement and injection.

When Its Not a Consultation

Another step in submitting claims for consultations is to understand when a service is not a consultation. This hinges on whether a transfer of care occurred. For example, an emergency department (ED) physician refers a patient with a broken wrist to an orthopedist. The ED physician has put a temporary splint on the arm, but sends the patients to the orthopedic specialist for major fracture care. The orthopedist sets the fracture, applies a short arm cast and instructs the patient to return in four weeks for an x-ray and possible cast removal. This is a referral for treatment and is no longer a consultation. The patient is officially a patient of the orthopedist.

The assumption is that the orthopedist will be completing the care for the patients fracture and should report 25600 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture or ulnar styloid; without manipulation). Any problem, complication or service related to the treatment (25600), which has a 90-day global period, is the responsibility of the orthopedist. And because, particularly in an ED setting, the patient is unlikely to return to the ED physician to finish his care, the initial E/M code for the visit is not a consultation code either. The patient was referred to the orthopedist with the intention of handing him over.

Stout explains that even if the orthopedist sends a note back to the ED or primary-care physician that acknowledges the referral and explains the treatment plan for the injured patient, this scenario would not qualify as a consultation. CPT clarifies that once the physician assumes responsibly for treating the patients condition, its no longer a consultation, says Stout. The only way the situation described would qualify as a consult is if the orthopedist simply looked at the arm, said, Yes, its broken, and sent the patient back to his PCP for treatment of the fracture, which we know would never occur.