Practice Management Alert

Want more reimbursement for a consult? Check for the 3 R's With physicians using the word "referral" so freely, billers can have a hard time telling whether they're requesting a consultation or a transfer of care. Use the Three R's - Request, Render and Report - to sort out this classic conundrum.
 
Doctors frequently say to patients, "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 when reporting it to the billing office. 
 
"The providers know what they want - they just don't know what they want in coding terms," says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver. That means it's up to you to figure out the referring physician's true intent.
 
The essential determining factor is whether a physician intends only an opinion from another provider (in which case you report a consult code, 99241-99245), or whether he intends for that provider to take over care (code new patient visit, 99201-99205). To complicate things a bit more, the 2004 CPT manual tells you: "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." Therefore, be careful not to code a new patient visit just because you see that a consulting physician has initiated services. In some circumstances, a consult includes rendered services and follow-up visits.
 
Tip: 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 as long as you have proof there was no intent to transfer care on that visit, Hammer says.
 
Regardless of what services the physician renders, you can identify a consult every time by checking for three required components.
 
Many billers rely on the Three R's, Hammer says. "There has to be a Request for an opinion [it must be documented], that opinion needs to be Rendered [it must be performed and documented in the patient's medical record], and there needs to be a written Report sent back to the requesting provider" or other appropriate source. 
 
Usually the appropriate source is a family practitioner sending a patient to a specialist for consultation. However, Hammer says, the source can also be a specialist practice sending a patient to a general provider for consultation on overall physical condition or for clearance for surgery. In that case, the general provider gets to bill for a consult.
 
The bottom line is money. Consults [...]