Orthopedic Coding Alert

You-ve got advice on accurate consult coding coming at you from all sides -- AMA, payers, specialty societies, and more. Calm the storm by getting back to the basics of what a consult really means to keep that audit bull-s-eye off your back.

Specialty knowledge: The intent of a consult, according to CMS, is for one provider to ask another for an opinion "because that individual has expertise in a specific medical area beyond the requesting professional's knowledge." So the fact that your surgeon has specialty knowledge is important, but you have to look at additional factors to determine whether you may code a consult, says Quita W. Edwards, CCS-P, CPC-Ortho, CPC-I, with C.A.S.E. Contracting Services in Fort Valley, Ga.

The R-s: Your first step is to verify that the encounter qualifies as a consult, not a standard patient visit. You can tell by checking for the R's of consultations. Traditionally you have three R-s, Edwards says:

- Request: A qualified provider must offer a formal request -- documented in the record -- asking your surgeon for advice or an opinion on a specific problem. Careful: A note stating the surgeon should perform a procedure is not a request.

- Render: The surgeon renders the service.

- Report: The surgeon reports findings and recommendations to the requesting physician.

Some consultants also suggest you add Reason before Request, meaning both parties should document a medically necessary reason for the request. And you also may add Return after Report as an extra guarantee that a transfer of care didn't occur before the Request.

If the visit qualifies as a consult, report the appropriate code from 99241-99245 for an office or other outpatient consultation for a new or established patient; report 99251-99255 for an initial inpatient consult.

If the visit doesn't qualify, report it as a new patient or follow-up visit, depending on the circumstances. This includes E/M codes 99201-99205 for a new patient office or outpatient visit or 99211-99215 for an established patient visit.