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. [...]