Radiology Coding Alert

You'll find the Three-R's CMS rule on their Web site at www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf, section 30.6.10.

Helpful: When coding E/M services, you may choose your code based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician and the patient AND you meet the requirements for consultation, Grady says. Red flag: The key is documentation. The records should show the provider spent X minutes counseling the patient out of a session totaling Y minutes. The provider should also document the topics covered in counseling and describe the coordination of care.

Never: CMS instructs you not to use standing orders for consultations. Instead, you need a distinct request for a consult for each patient before coding and billing this service.

Watch for Preoperative Consultations

If a surgeon requests that your radiologist perform a preoperative evaluative consultation to determine whether a patient should receive a particular treatment or to assist in choosing among a variety of treatment options, Medicare typically will pay as long as you meet the Three R's AND all the requirements of the code. If your physician doesn't provide medical decision-making (MDM), you can't separately code the pre-op visit.

Example: A gynecologist asks your radiologist for a consultation to determine if a patient is a good candidate for uterine embolization. The radiologist does a thorough history, reviews prior studies, answers patient questions, and performs a physical exam and a pelvic MRI to assist in MDM. Because the gynecologist requests the visit, report a consultation code (99241-99245) for this visit, says Terrence Leone, CPC, CIC, CMBS, radiology coding specialist with Catamount Associates in New York and member of the AAPC National Advisory Board.

You may also need to look to your E/M section for vertebroplasty candidates. If an orthopedist sends a patient to your radiologist, who performs an exam, reviews an MRI the orthopedist ordered, and sends a report with his opinion of the benefits to the patient, for example, report the appropriate consult code (99241-99245). Remember: The MRI review is part of the E/M, so don't report this review separately.

Snag: If your radiologist provides a preoperative consultation and later assumes at least a portion of the patient's postoperative care, many payers tell you not to use consultation codes for the post-op visits. Instead, they ask you to report subsequent care codes for post-op encounters in the hospital and established patient visit codes in the office, assuming you don't have to include the care in the global period. Smart: Check your payer's policy for post-op coding preferences.

If the surgeon requests only a postoperative consultation from your radiologist (who didn't offer a preoperative consult), code the post-op consult, the CMS guidelines say.

Explain 2 E/M Codes From the Same Practice

If the referring physician and consulting physician are from the same practice, you could be in for some extra work. "Most payers will only pay for one E/M on the same day," says Sandra Soerries, CPC, CPC-H, a coding consultant with BKD in Kansas City, Mo.

Don't give up: Appeal the denied claim and explain why the patient needed to see two physicians on the same day, she says. Bolster your argument with Section 30.6.10.C of Chapter 12 of the Medicare Claims Processing Manual, which instructs carriers to "pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met."

Tip: Appeals involving two physicians with the same specialty rarely pass muster, but if one physician uses the unique specialty interventional radiology code and the other the diagnostic radiology code, you'll have a better shot because each physician can document his separate scope of service. Another option: If your payer simply won't pay for that second E/M, consider scheduling the second visit for a different day.

The same source states that nonphysician practitioners may request a consultation or perform it if the service is within their scope of practice. Document that each provider managed a separate aspect of patient care.

Opt for Confirmatory for Self-Referral

When a patient requests a second opinion from your radiologist after being seen by another physician, don't report a straight consult - look to confirmatory consult codes instead (99271-99275), Soerries says. And if the request is for a confirmatory opinion on a radiologic imaging test performed elsewhere, choose the correct code from the radiology consultation codes in the 70000 series - not the E/M consultation codes.

Caution: Some payers deny confirmatory consult claims, so check your contract and payer guidelines to determine if you'll need to ask the patient to pay for this service. For Medicare, consider obtaining a signed Advance Beneficiary Notice from the patient, in which he acknowledges that he'll be responsible for footing the bill if Medicare won't.

Treat Yourself to Treatment and Consult Codes

If your documentation includes the 3 R's and a therapeutic procedure, such as embolization or abscess drainage, you can report both the procedure and the E/M. Medicare will pay for treatment and an initial consultation on the same date unless a transfer of care occurs, states section 30.6.10.B of Chapter 12 of the Medicare Claims Processing Manual. Remember to add -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if the service merits it.
 
Note: You can receive a free "Quick Documentation Checklist for Consultation Coding" by e-mailing Radiology Coding Alert editor Deborah Dorton at deborahd@eliresearch.com.