Otolaryngology Coding Alert

Standard request form will help ensure you meet all the requirements

In addition to the established three R's of consultation coding--request, render, and report--your physician must supply a documented reason for you to be able to successfully report a consultation, says CMS- Transmittal 788. Follow this expert advice to make sure your documentation stands up to the new standards.

The Proof Is in the Details of Your Documentation

To fulfill this new requirement for a reason, make sure the requesting physician specifies in the original consultation request why the patient needs the service before you report a consultation code.

In the past, your physician may have simply written -allergy consult- at the top of his consult note when he performed a consultation at another physician's request. Instead, under the new guidelines, the allergist should write something like -allergy consult per internist's request- and include the reason for the request.

The medical record should indicate that another physician requested a consult, CMS official Kit Scally said during the Jan. 20 physician Open-Door Forum. If an allergist meets another physician in the hospital hallway and verbally requests a consult, both physicians should document that fact in their records. If the allergist or his staff phones in the consult request to the other physician's staff, you should document that circumstance too, Scally said.

Avoid Unnecessary Pre-Op Clearance Requests

Because you have to provide a specific reason for the consultation, you won't be able to report preprocedure clearance visits that aren't medically necessary as consultations, coding experts say. Your allergist will have to be careful when he asks another physician to perform a consultation and clear a patient for a procedure. Without documented medical necessity, the consulting physician will be out of luck when he tries to capture reimbursement for the consultation.

Sometimes allergists obtain a medical consultation from another physician as a preventive measure prior to performing a procedure. In the past, the documentation for the consultation might have just said -medical clearance.- Now if your physician doesn't identify some specific reason that the patient needs the clearance, payers will consider the visit a screening, not a consultation.

Capture All Details With a Standard Request Form

Both the consulting and primary physicians should document the request for a consultation in the patient's medical record, CMS says.

Heads up: You can't simply make sure the requesting physician's file has the consulting physician's report after the fact. The request for the opinion must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. This change for consultations will undoubtedly disrupt the normal smooth flow of office care and patient visits, some coding experts say.

Tip: Use ordering slips when your physician requests a consult and ask for a written request when a physician sends a patient to your office for a consultation. If a physician regularly sends patients to your office, you should think about supplying his office with ordering slips, similar to the ones radiologists and clinical labs use.

You can use a form that you can fax to the requesting physician's office, says Patricia Trites, MPA, CHBC, CPC, CHCC, CHCO, CEO of Healthcare Compliance Resources in Augusta, Mich. The requesting physician can keep this form in the medical record, which solves your documentation problems and also helps to accurately and clearly indicate the reason for the consultation request.