Question: Why do I keep getting denials when I bill for a consultation visit before surgery or other procedures?
- Louisiana Subscriber Answer: If a physician sends a patient to a surgeon for a consultation, and the surgeon schedules a procedure right away, it won't look like a consult to carriers or auditors.
"Consults are always evaluation and management services," says Marcella Bucknam, CPC, CPC-H, HIM coordinator at Clarkson College in Omaha, Neb. "They're never procedures." So if the requesting physician writes something like "Please perform a biopsy on this patient," it's automatically not a consult. The patient record should show that Dr. A wants to know what Dr. B thinks of a patient's condition.
Likewise, Dr. B's documentation should not say the patient came to him for a procedure. Instead, the chart should document an E/M. The chart should indicate that Dr. A sent the patient to Dr. B for another opinion, what Dr. B found, and the patient's history, exam, and the medical decision-making. Dr. B should conclude by saying, "We've communicated our findings back to Dr. A, and we're going to schedule surgery," Bucknam says. This has all the elements of an E/M consultation because the Three R's (request, review and report) are satisfied.
The chart should also include a copy of the letter back to Dr. A that recounts the patient's history, even though both doctors already know it. If Dr. B merely writes back to Dr. A and says, "I saw Mary Jane. She's well known to you," that won't prove a consult took place, Bucknam says.
The key is proper documentation. Without it, you'll end up being able to bill only for a new patient or a follow-up established patient visit instead of a consult. That can mean a huge loss of money. Instead of the $200 you might get for a consult, you could receive only $40 to $50 for a follow-up visit.
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