Orthopedic Coding Alert

Question: Can physicians of the same specialty request or receive a consult from other physicians of the same specialty? For instance, orthopedist A requests a consult from orthopedist B.

Utah Subscriber

Answer: Yes, physicians of the same specialty can request and receive consultations (99241-99245, outpatient, or 99251-99255, inpatient) from one another. A Medicare-produced Medlearn Matters article (MM4215) clarified that a physician can provide a consultation for another physician of the same specialty. 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 physician's record, 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 for the consult.

Be aware, however, that the same practice cannot report two inpatient consultations for the same patient during the same hospital stay.

For instance, if an orthopedist admits the patient and consults with a partner who has more experience in that specialty, the partner can bill a consult (although you may have trouble getting paid for both doctors on the same day).

If, however, orthopedic surgeon A provides an inpatient consult for another physician and then requests a consult from orthopedic surgeon B in the same practice who has more experience, you may not report the second visit as a consultation.

-- Reader Questions and You Be the Coder were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.