Otolaryngology Coding Alert

Make Sure Your Consults Aren't Really Transferes of Care

Published on Wed Sep 08, 2004

Learn the difference between 'refer' and 'consult'

When your allergist provides consultation services, be sure that the visit meets all the consult requirements before billing it as such, and be careful of the language you use to describe the patient visit.

Medicare paid $2 billion in 2000 for consultations (99241-99263), and in 2004 the Office of Inspector General, as outlined in its annual Work Plan, wants to determine whether practices - including your allergy practice - are reporting these codes appropriately.

Don't Be Fooled by Imprecise Terms

Just because another physician "refers" a patient to your allergist doesn't mean you should assume the visit is a referral or transfer of care. Choosing a standard outpatient code instead of a consult (when the consult is appropriate) will cut into your practice's bottom line (because outpatient visits pay less than consults).

"Doctors frequently say to patients things like, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.

Let the "Three R's" guide you: Likewise, if the allergist says he "consulted" with the patient, you shouldn't automatically choose a consult code. A "consult" as defined by CPT describes a very specific service that involves three components:

a request from another physician for a consult

an opinion rendered by the consulting physician

a report on the patient's condition sent by the consulting physician to the requesting physician.

Using these criteria, you can separate the consults from the transfers of care.

Self-Referrals and 'Recommendations' Don't Count

If a patient visits your allergist at the "recommendation" of another physician or on his own accord, you must select a standard outpatient E/M code (99201-99205 for new patients, or 99211-99215 for established patients) to report the service.

"The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group," says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga. But you cannot bill for a consult if "the attending physician did not specifically ask for an opinion or advice from the specialist," she adds. This request from the attending physician must be recorded in writing and be available as a part of the patient's medical record.

Some Care Doesn't Mean 'Transfer of Care'

You may report a consult even if your allergist schedules testing or initiates care for the patient - as long as the visit meets the requirements of request, render and report.

CPT 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." You should not code a new patient visit just because you see that a consulting physician has initiated diagnostic testing or treatment services.

Further, in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the consulting physician initiates treatment, as long as all consultation criteria are met and no transfer of care occurs.

Appeal Insurers' Downcoding

Many insurance companies that see a consult code alongside a treatment or procedure will automatically downcode the claim to a new patient visit. You should appeal these claims (and your lost reimbursement) as long as you have proof there was no intent to transfer care on that visit, Hammer says.

Example: A primary-care physician requests that an allergist provide a consultation for a patient complaining of recurrent bronchitis, which could be caused by allergies to airborne substances in the workplace. The allergist meets with the patient, conducts a number of tests and spends some time with the patient discussing possible diagnoses and treatment options. The allergist prepares a report of her findings and sends it to the requesting physician.

In this case, you would report a consult: No transfer of care has occurred at this point, and the allergist has met the requirements of request, render and report.

If Physician Takes Over Care, Use Outpatient E/M

If, after an initial consultation, the consulting physician accepts primary care for the patient's condition, you must report all subsequent visits using the appropriate-level outpatient E/M code.

"A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance," explains the Medicare Carriers Manual, section 15506.

Coding example: Returning to the above case: After the initial consultation, the allergist accepts responsibility for diagnosing and treating the patient's bronchitis. On subsequent visits, the allergist will report established patient office visits (99211-99215), as well as any testing or treatment codes, as supported by documentation.