Otolaryngology Coding Alert

CMS withdraws consult article, but experts still agree no letter necessary

Even though a Medicare decision clarified that you don't need a letter to meet a consultation's request criteria, you may still want to obtain written confirmation to protect your otolaryngologist's consultation dollars.

Count Verbal Request as Consult's First Part

CMS had issued a new "Medlearn Matters" article that addressed a consultation's first "R" requirement: Request. The agency said that otolaryngologists don't need a letter from the primary-care physician (PCP) to prove the physician requested the specialist's opinion. Instead, CMS said, you just needed a note in the patient's medical record.
 
But now CMS has removed "Medlearn Matters" article SE-0515 from its Web site and told the carriers to take the story back.
 
Luckily in the case of consults, CMS' new advice wasn't too different from what consultants have been telling clients for years, says Eric Sandhusen, CHC, CPC, director of billing and fiscal compliance with Columbia University department of surgery.
 
Key: You don't need a letter from the referring physician, but you do need request-of-opinion documentation, in at least the consulting physician's files and ideally in both doctors' records.

Back Up Opinion Request With Simple Sentence

Sometimes otolaryngology coders believe that patients need to show up for a consult with a note or prescription from the referring physician requesting the consult, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa.
 
The Medicare Carriers Manual says the record must have a written "notation" of the request for consult, but not that it has to be a request in writing.

Often, one physician will call up another, or meet him in the hallway, and request a consultation verbally,  Sandhusen says.
 
In that case, the consulting physician should simply write in the patient's progress notes that she's evaluating the patient at the request of Doctor X, Falbo says.
 
Good idea: If your office doesn't have forms for requesting physicians to use or if the primary-care physician doesn't issue written requests, encourage your otolaryngologist to document the request in the first sentence of his report.
 
Here's how: A pediatrician calls and asks your otolaryngologist to see a child who has had frequent ear infections. To support an outpatient consultation (99241-99245, Office consultation for a new or established patient ...), your otolaryngologist should note: "I am seeing this patient at Dr. Smith's request for my opinion about the child's multiple cases of otitis media (OM)."
 
Don't forget: Of course, the otolaryngologist would also have to render his opinion and report his findings to the pediatrician. The "render" and the "report" make up a consultation's second and third requirements and are necessary to bill the OM example as 99241-99245 with a diagnosis of OM, such as 381.10 (Chronic serous otitis media, simple or unspecified).

Use Form for Rock-Solid Proof

Some consultants do recommend making your own form for consults, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute. That way, when you receive the phone call from Dr. X's office, you can fax a form for Dr. X to sign requesting the consult. CMS doesn't require a request fax confirmation, but the form offers extra protection.
 
The fax serves two duties. First, the fax supports your consultation coding. "It also encourages the primary-care physician to document the request for opinion in his records," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. That way, if CMS ever audits you, you have proof of the PCP's intentions.
 
Why the flip-flop: CMS has been making documentation calls that are the AMA's territory, Falbo says. CMS is supposed to consult the AMA before making changes to documentation guidelines through transmittals and other means, she says.