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 [...]