Otolaryngology Coding Alert

Warning:  Avoid reporting consultation codes for shared/split visits

Consultation coding has undergone many changes this year, and you-re not alone if you are struggling to keep up. We-ve got the inside scoop on a CMS Transmittal that will simplify coding for your allergist's consultation services.

Physician's Area of Expertise Makes the Difference

The most significant clarification in CMS Transmittal 788 is that if your allergist works in a group practice, you can still report and be compensated for consultations that he provides for other physicians in the group. But to ensure reimbursement, the consultant's knowledge and expertise must go above and beyond that of the requesting physician-s.
 
This requirement will apply to allergy groups in which physicians have subspecialties, and to more diversified practices that might include physicians in other specialties such as pulmonology or general medicine. While it's been pretty clear that you could report consultations within a group between physicians with separate specialties, same-specialty consultations within the same group were not clearly allowable, says Deborah J. Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, president of Medical Professionals Inc. in Indianapolis.

Tip: This guideline also clarified that physicians should not routinely request a consultation from another member of their group, Grider says. Your protocol cannot be that if a patient comes in to see Dr. A, he then automatically sends the patient over to Dr. B after he finishes his examination. Make sure your office can prove that the allergists have separate subspecialties and that there is a medical necessity for the second physician to see the patient in consultation.

Transfer of Care Eliminates Consult Code Options

Make sure you don't report a consultation if there is a transfer of care between physicians in the same group, says Nancy Reading, RN, BS, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, Utah. If the second physician assumes care of the patient prior to the visit, a consultation code is not appropriate, as the following examples demonstrate.

Example: A primary-care physician diagnoses one of her patients with asthma and allergic rhinitis. To determine which environmental factors trigger this patient's symptoms, the primary-care physician refers the patient to an allergist for testing and treatment.
 
Because the allergist is assuming care for this condition, and an opinion or advice is not being sought,  the visit is not a consult. In this example, the allergist should report the appropriate established patient office visit code for the encounter rather than a consultation code.

Forego Split Visits for Consultations

Good news: Your nonphysician practitioners are still able to report and request consultations, according to CMS- transmittal.

Bad news: The agency also clarified that you cannot report a consultation that involves a shared or split visit between the allergist and the NPP. Some practices may have been previously advised by their carriers not to use shared visits for consultations, but this may be a significant change for some physicians.

Often in allergy practices, a nurse practitioner performs the patient workup. The allergist then provides a key portion of the service -face-to-face- and bills for the whole visit. Shared visits such as this are not permissible with consultations. Therefore, when your allergist is performing a consultation, your office's nurse practitioner or physician assistant can only contribute the review of systems or past medical, family and social history toward the documentation and visit level that the physician provides and selects.