Otolaryngology Coding Alert

Time-saver: You don't always need fax request proof

Before you complete another fax request form or send one out, check out these two rules that will save you from spending time on unnecessary paperwork.

Recent CMS rules have created a flurry of paperwork as consulting physicians strive to provide evidence of the other physician's written request. In an attempt to reduce this time-consuming paper trail, Medicare came out with a recent clarification that may let the consultant off the hook.
 
-On April 18, 2006, the PRIT (Physician Regulatory Issues Team) released a statement indicating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient chart,- writes Diane Daigle, president of MeMGMA (Maine Medical Group Management Association).

But that statement doesn't mean you should stop using fax confirmation forms or that you shouldn't respond to other physicians- requests that you do so. Implement proper form protocol using two guidelines.

Rule 1: Avoid Faxing Consult Requests to Referrals

Scenario 1: We are a small ENT practice and we often refer patients to a local allergist. The allergy practice saw your April article -Use This Sheet to Coordinate Your Consult Documentation,- which recommended that otolaryngologists fax a consult request form to the requesting physician before the surgeon performs a consult. This way, the ENT ensures that he always has consult requests in writing. But this allergist faxes us the form every time we send any patient to him -- even when we are transferring care of the patient to the allergy practice. Is this necessary?


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-You are best served if you have either a faxed request or a formal form that the otolaryngologist completes,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. If you have already sent a consult request in writing to the allergist, you don't need to fill out another consult request form.

Do this: The only time the allergist will need to send your practice the consult request form is when one of your ENTs specifically asks the allergist to perform a consultation but fails to put his consult request in writing, Cobuzzi says. In those cases, the allergist can send your practice the form to ensure that you-ve given him clear documentation of the consult request.

If you simply refer a patient to the allergist -- meaning that your otolaryngologist transfers the patient's care to the allergist -- then from a coding standpoint, there is no need for a written request of the referral. In fact, if the allergist asks you to fill out the consult request form every time you refer a patient, there is a chance that he is actually billing the visits as consults (99241-99245) and not as new/established patient office visits (99201-99215). If that is the case, he may be upcoding the visits, because consults pay more than office visits.

In addition, if you always send your consult requests to the allergist in writing, you shouldn't need to fill out the consult request form, since you-ve already provided a written request for the service.

Rule 2: Use Request Sheet to Protect Consult Pay

Scenario 2: A pediatrician requests an otolaryngologist's opinion regarding a child who has had frequent ear infections. The otolaryngologist documents the request and codes the service, which includes a report back to the pediatrician as a consultation. What proof does the ENT need to substantiate the pediatrician's written request?

The PRIT's April statement means this extra step isn't necessary. CMS clarified that the consulting physician doesn't have to verify that the requesting physician documented the request for a consult. That means the ENT isn't responsible to make sure the pediatrician's files include that request in writing.

Be careful: But CMS officials still insist that the requesting physician has to document the request for a consult, as CMS stated in last December's Transmittal 788. The only change is that the consultant doesn't have to verify that the requesting doctor has done so.

So, what will happen if the carrier audits the otolaryngologist and doesn't find any request documented in the pediatrician's files? Will the specialist still get paid? At this point, CMS hasn't been able to answer that question.

-It is a real paper chase for the consultant to have to look at the referring physician's notes to see if they are in compliance,- says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif. CMS should delete the requirement for the requesting physician to document the request for a consult altogether, she adds.

The issue isn't resolved: CMS officials say they-re not planning on clarifying the consult issue any further -- unless providers or carriers indicate that they-re still having problems. CMS doesn't even plan to put out a transmittal or manual update spelling out this latest clarification partly letting consulting physicians off the hook
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Best bet: Ensure that your office documents all consult services carefully. If possible, insist that the physicians requesting those services do the same by using a -consult request sheet- as provided in the April 2006 Otolaryngology Coding Alert. Tell reciprocal offices that they can avoid fax work by sending this paperwork with the patient.

Rule 3: Commit the 5 R's to Memory ~ or Your Board
 
As always, you should let documentation guide your coding. Now, more than ever before, you must have a documented reason and request for the consult, along with an opinion rendered by the consulting physician with a report sent to the requesting physician.

Experts also recommend adding the -fifth R- of returning (or discharging) the patient back to the requesting physician when the episode of care is complete. The five R's of a consultation for 2006 are (* indicates new this year):

- Reason*: medically necessary -- both the requesting and consulting physicians must document the reason and request for the consultation. But the consultant doesn't have to verify that the requesting physician did so.

- Request: by another physician or other appropriate source.

- Render: the consulting physician may initiate diagnostic and/or therapeutic services.

- Report: the consultant must issue a written report to the requesting source.

- Return* (recommended by consultants as proof that a transfer of care has not occurred): the patient goes back to the requesting physician.