Urology Coding Alert

Without a documented reason, you can forget reporting a consultation

You can probably recite the three R's of consultation coding in your sleep: request, render, and report. Now you have one more R requirement to add to your mantra--a reason. And without it, you won't be able to successfully report a consultation.

The Proof Is in the Details of Your Documentation

Without a documented reason for the consultation, you won't see any money for your physician's service. Make sure that the requesting physician specifies in the original consultation request why the patient needs the service before you report a consultation code.

In the past, your physician may have simply written "urological consult" at the top of his consult note when he performed a consultation at another physician's request. Instead, under the new guidelines, the urologist should write something like, "urological consult per internist's request," and include the reason for the request.
 
The medical record should indicate that another physician requested a consult, CMS official Kit Scally insisted during the Jan. 20 physician Open-Door Forum. If a urologist meets another physician in the hospital hallway and verbally requests a consult, both physicians should document that fact in their records. If the urologist or his staff phones in the consult request to the other physician's staff, you should document that circumstance too, Scally said.

Avoid Unnecessary Pre-Op Clearance Requests

Because you have to provide a specific reason for the consultation, you won't be able to report presurgical clearance visits that aren't medically necessary as consultations, coding experts say. Your urologist will have to be careful when he asks another physician to perform a consultation and clear a patient for surgery. Without documented medical necessity, the consulting physician will be out of luck when he tries to capture reimbursement for the presurgery consultation.

When your urologist is planning surgery for a patient, he may obtain a medical consultation from another physician as a preventive measure. In the past, the documentation for the consultation might have just said "surgical clearance." Now if your urologist doesn't identify some specific reason that the patient needs that surgical clearance, payers will consider the visit a screening, not a consultation.

Example: A urologist refers a patient to an internist for medical clearance before a surgical procedure. There must be a documented medical reason, such as a heart condition, hypertension or diabetes, for why the urologist wants the internist to clear the patient for surgery if the internist is going to bill for a consultation.

Capture the Details With a Standard Request Form

As the consulting physician, your urologist needs to have a documented request in the patient's medical record, but the requesting physician must also include the request in the patient's medical record, CMS says.

Heads up: You can't simply make sure the requesting physician's file has the consulting physician's report after the fact. The request for the opinion must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. This change for consultations will undoubtedly disrupt the normal smooth flow of office care and patient visits, some coding experts say.

Tip: Consider using ordering slips when your physician requests a consult and asking for a written request when a physician sends a patient to your office for a consultation. If a colleague regularly sends patients to your office, you should think about supplying his office with ordering slips, similar to the ones radiologists and clinical labs use. You can use a form that you can fax to the requesting physician's office, says Patricia Trites, MPA, CHBC, CPC, CHCC, CHCO, CEO of Healthcare Compliance Resources in Augusta, Mich. 
  
The requesting physician can keep this form in the medical record, which solves your documentation problems and also helps to accurately and clearly indicate the reason for the consultation request. (Look for a sample consultation request form in the next issue of Urology Coding Alert.)