Orthopedic Coding Alert

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 and potential fines, Callaway-Stradley explains.

Consults vs. Transfer of Care

In addition to meeting the above criteria, there would have to be no intent to transfer care by the original physician. For instance, a knee specialist has been treating a patient with an ACL injury. During the visit, the patient complains of wrist pain that the knee specialist determines to be carpal tunnel syndrome. He suggests that the patient make an appointment to see the hand specialist in the same practice for treatment.

This type of scenario, which is more common in orthopedic practices, would not be a consultation but would be a transfer of care, because one orthopedist would be skilled in an area the other is not. The codes for the hand specialist would be from the established patient series (99212-99215) since the patient would not qualify for consult codes or new patient codes. The rule for a new patient is, No services for three years by that physician or any other physician in the same practice, of the same specialty, Callaway-Stradley remarks.

It happens quite a bit, explains Christine Banks, RRA, CPC, an orthopedic coding specialist at Massachusetts General Hospital in Boston, MA. A patient will come to our foot and ankle doctor with arthritis and they may have a tumor, so the ortho-oncologist would be called in as well.

The decision to code for a consult versus a transfer of care is based on specific subspecialty skills. It definitely has to do with skill, Banks explains. If it is a true consult, you would be asking only for an opinion.

However, the division between a consult versus transfer of care isnt always easy to spot. Most of the confusion stems from the wording in Item A in Section 15506 of the MCM, which says that a consulting physician may initiate diagnostic and/or therapeutic services. But then the last line of Item A, which sites HCFA, confuses the issue, Callaway-Stradley points out. However, when the referring physician transfers the responsibility for treatment to the receiving physician, at the time of the referral in writing or verbally (i.e., following the request to evaluate and treat), the receiving physician would not continue to bill a consultation code.

Its that word continue that confuses everyone, Callaway-Stradley explains. If care is transferred at the time of the initial referral, the subspecialist wouldnt be continuing to do anything. This would be the first time he or she saw the patient.

The next sentence of Item A is also confusing: He or she would bill a subsequent hospital care code (99231-99233) in the hospital setting or an appropriate established patient code in the office setting (99212-99215).

Understandably, many subspecialists, who have never seen this patient before, question, subsequent to what? Callaway-Stradley explains that the former way of interpreting Medicare consults was that if an admitting physician called another physician to see his or her patient, the first visit was always a consult.

This vague wording seems to be focusing on the intent of the call to the specialist (or subspecialist), she says. If the physician who is calling you can no longer take care of this problem, and your specialty or subspecialty is the one that can, then the basic intent is a transfer of care, not a consult.

Tip: Even though the Section 15506 of the MCM states Medicare will reimburse consultations by physicians in the same group, some carriers may interpret this differently, so always contact your carrier before billing.