Pediatric Coding Alert

Your payments depend on updating the 3 R’s to 5

Consultation requirements have increased in the last year. Here’s what you must do to ensure that your 99241-99255 claims are justified.

The old-school three R’s of a consultation have been shifting. In the last year, the Centers for Medicare & Medicaid Services has issued two statements increasing the documentation requirements for consultations.

Important: These are Medicare guidelines only, but they are generally accepted by private payers.

Reacquaint Yourself With the 3 R’s

Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:

• Request for opinion
 
• Rendering of services

• Report to the requesting source.

First on Medicare’s chopping block were qualifying requesters. “New CMS guidelines require a physician to make the request,” says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. However, CPT specifies that the request can be from a physician or other appropriate source.

Protect Yourself With Written Reason and Request

Last December, CMS added reason to the consultation R’s. Transmittal 788 requires that the requesting physician document the request and the reason for a consult in the patient’s medical record. This advice existed as spoken instruction, but it had never before been given in writing, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Helpful tool: To help ensure that requesting physicians meet the new requirement, Cobuzzi created a reverse request fax consultation form. Consultants can fax the form to the requesting physician to be filed in the patient’s chart. “We can’t make [the requesting source] file the form, but using the tool at least increases the chances that there is something in the chart,” Cobuzzi says.

CMS Partially Lets Consultants Off the Hook

The ensuing paperwork trail led CMS to reconsider the feasibility of making the consultant responsible for the requesting physician’s documentation. “On April 18, 2006, the PRIT (Physician Regulatory Issues Team) released a statement stating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient’s chart,” writes Diane Daigle, president of Maine Medical Group Management Association. When an appropriate source requests a consult, the consultant isn’t responsible for making sure the requesting physician’s files include that request in writing.

That’s not all: CMS officials still insist that the requesting physician has to document the request for a consult. The only change is that the consultant doesn’t have to verify that the initiating doctor has done so.

So, what will happen if a carrier audits the consultant and doesn’t find any request documented in the requesting physician’s files? Will the consultant 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 requesting 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, which partly lets consulting physicians off the hook.

Best advice: As always, you should let documentation guide your coding. Now, more than ever before, the consultant must have a reason and request for the consult documented in the patient’s medical record, along with an opinion rendered by the consulting physician, with a written report sent to the requesting physician.

Look for Complete Circle of Care
 
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.

Remember: The “return” does not always occur at the end of the consultative service. “The consultant is permitted to initiate treatment, when appropriate, and still report a consultation,” says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. When the consultant completes the course of treatment, eventually discharging the patient from his care, a notation in the medical record helps distinguish between ongoing care and future consultation requests, Pohlig says.

Refer to the New Consultation 5 R’s

Keep the consultation requirements straight with these basics from Tuck. The five R’s of a consultation for 2006 are (* indicates new this year):

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

• Request: The request must come from another physician. CPT also allows requests from other appropriate sources.

• Render: The consultant must render services during which time he may initiate diagnostic and/or therapeutic services.

• Report: The consultant must issue a written report to the requesting source

• Return* (recommended by consultants): To show that a transfer of care has not occurred, the consultant should send the patient back to the referring physician