How to Code Consults within the Same Practice
Published on Sun Aug 01, 1999
If an orthopedic surgeon sees a patient for a consultation and then refers the patient to a partner in his or her own medical group for an opinion, can that second physician also bill for a consultation? Its an interesting question that affects many orthopedic practices with multiple physicians, and recently came into question at the Arthritis, Orthopedic and Sports Medical Center in Glendale, CA.
Can the internal consult be coded 99241-99245 (outpatient consult), instead of using the subsequent outpatient care visit codes (99211-99215)? This is a key question for orthopedic practices who do intra-office consulting, because the group could significantly increase its revenue if outpatient consults were used. However, incorrect coding in this area could bring auditors knocking on your door.
Intra-office Consults Must Meet Requirements
Our experts says that Medicare will recognize consults between physicians within the same specialty. However, they will expect all of the requirements of the consultation to be met: a request, a specific need, and a written report back to the original physician with recommendations on how the original physician can treat the patients problem.
How does this translate in real life? If your documentation were to be reviewed, it would be expected that the consulting physician has some unique skills that are needed that the other orthopedist does not have. In this situation would you bill a 99244 (office or other outpatient consult) or 99215 (office or other outpatient service; establisted patient)?
The answer depends on the interpretation of Item C in the Medicare Carriers Manual (MCM) Section 15506: Consultations Requested by Members of Same Group. The paragraph 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 the requirements for use of the CPT consultation code are met.
Note: You can download this section from www.hcfa.gov. Go to Medicare, Professional/Technical Information, Medicare Professional/Technical publications, Medicare/Medicaid Manual.
So you can bill a consult if the documentation supports the criteria of a consultation. But that is a big if, warns Susan Callaway-Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott Davis and Co., LLP, an accounting and reimbursement firm in Augusta, GA.
The documentation of both requesting and consulting [physicians] have to meet the criteria. If it does, Medicare should pay for the consult, she explains. But if the documentation doesnt meet the criteria, then you should not be billing it. The fact is, many consultations being billed are not true consults.
Thats why a thorough understanding of the criteria is vital. It will determine whether your practice can ethically increase its reimbursement by billing subspecialty consults or whether it will trigger an audit [...]
