Orthopedic Coding Alert

Question: In our orthopedic practice we have two family practice physicians who are board-certified in sports medicine. May we charge a consult when a patient is referred to them from another family practice physician?

South Carolina Subscriber

Answer: Yes, physicians of the same specialty may request and receive consultations (99241-99245, outpatient; or 99251-99255, inpatient) from one another.

CMS- MLN Matters article MM4215 clarifies that a physician may provide a consultation for another physician of the same specialty (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf). The service must meet two minimum conditions, however:

1. Documentation must verify all elements of a consultation service, including a request for consult in both the requesting and consulting physicians- records, a reason for the consult request, and a written report from the consultant to the requesting physician outlining the consultant's findings and recommendations.

2. The consulting physician's knowledge and expertise must go above and beyond that of the requesting physician. In other words, the physician in the group being asked for the consultation must clearly have a skill set that the requester does not have. The chart must reflect the reason and justification (medical necessity) for the consult.

Because your family practice physicians are board- certified in sports medicine, they should meet the requirement that they have knowledge and expertise above and beyond that of the requesting physician.