Wiki Consultation codes 99242-99244

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medicalauditor

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Hello all. I need some opinions on two aspects of these services: 1. If the referring physician has sent over a "referral" which is referred to as a "referral" throughout their documentation, but the specialist calls it a "consultation" and bills it as a consultation, how would you determine if the service was really a consultation, or was it a referral where the specialist is going to take over care for the patient? Per the guidelines, the specialist can treat the patient for the problem and there can also be subsequent visits with the patient, so it is difficult to determine if the 1st visit was really a consultation, or a referral for treatment. I am aware that for a consultation, they are required to send a written report back to the referring physician, which brings me to my 2nd question - 2. The provider states in the chart note "A copy of today’s documentation is being returned to the requesting clinician which indicates my assessment and plan for this patient. Please review the report and let us know if you have any questions.", but there is no faxed document in the EMR or any other evidence that a written report was actually sent to the referring physician. Would you consider this statement enough, or would you, as an auditor, need to see evidence that a report was faxed/mailed to the referring physician?
Appreciate any opinions on this and if anyone has a resource which provides more guidance about this or differentiates between a referral and consultation, it would be great. Thank you!
 
1. Does the payer recognize consult codes is your first question.

2. A referral and consultation request are not the same thing. Mixing the two words is never a good idea.

3. The specialist can call it whatever they want, however if there was no specific written request, a reason for it, and report back it is not a consult. Think of it as the "3 Rs". If the intent was to transfer care and the specialist is taking over management, it's not necessarily a consult at that point. I have seen where every single new visit is billed as a consult by a specialist simply because they think it should be. The documentation was not a consult, it was assuming care and the patient was referred for management of a problem. The consult codes usually have higher RVU so they want to bill that instead of a new.

4. The written or verbal request for the consultation must be documented in the patient’s medical record, including the reason for the request. There should be a written report from the consultant to the requesting provider. It can be in the form of the chart note but it must be clear it was communicated back to the requesting provider. It could be in a shared record though if it is a big group so you would not necessarily see a fax or mail because it's a shared record. I would consider the statement you have there enough probably depending on the rest of the documentation.

5. Aside from the outpatient ones, there are other types of consult codes which may have other rules too.

Old links but info still the same: https://www.aapc.com/codes/coding-n...1O1JxjdTWLcHEY7c8n3JGFnTMQgagHduUJXitEuIvFf3-

A couple years old but good info and really answers your question:
"As an auditor, I am often left trying to determine, from the documentation provided, whether the intent of the visit with the specialist is truly a consult or a referral. The consultant often views every eligible service as a consultation, even as the consultation rules make clear this is not the case."


 
amyjph said:
1. Does the payer recognize consult codes is your first question.

2. A referral and consultation request are not the same thing. Mixing the two words is never a good idea.

3. The specialist can call it whatever they want, however if there was no specific written request, a reason for it, and report back it is not a consult. Think of it as the "3 Rs". If the intent was to transfer care and the specialist is taking over management, it's not necessarily a consult at that point. I have seen where every single new visit is billed as a consult by a specialist simply because they think it should be. The documentation was not a consult, it was assuming care and the patient was referred for management of a problem. The consult codes usually have higher RVU so they want to bill that instead of a new.

4. The written or verbal request for the consultation must be documented in the patient’s medical record, including the reason for the request. There should be a written report from the consultant to the requesting provider. It can be in the form of the chart note but it must be clear it was communicated back to the requesting provider. It could be in a shared record though if it is a big group so you would not necessarily see a fax or mail because it's a shared record. I would consider the statement you have there enough probably depending on the rest of the documentation.

5. Aside from the outpatient ones, there are other types of consult codes which may have other rules too.

Old links but info still the same: https://www.aapc.com/codes/coding-n...1O1JxjdTWLcHEY7c8n3JGFnTMQgagHduUJXitEuIvFf3-

A couple years old but good info and really answers your question:
"As an auditor, I am often left trying to determine, from the documentation provided, whether the intent of the visit with the specialist is truly a consult or a referral. The consultant often views every eligible service as a consultation, even as the consultation rules make clear this is not the case."


Click to expand...
Thank you! There is written communication from the referring physician on file, but like I said, it is standard referral documentation. Nowhere in the referral does it state that it is a consultation request. It is hard for me to establish that this was intended to be a transfer of care because this is a recent visit and follow-up appointments have not happened yet. The prior auth says that 1 visit was approved. Finally, I understand that sharing the chart note with a physician in a large group is sufficient to fulfill the "written report" requirement, but what if the referring physician is not in the group with the consultant and is an external physician? I don't know if an external physician can access the consultant's EMR, but I presume not. As you can see, all this is making it challenging for me to establish if this was or was not an actual consultation and if it was, then whether the 'written report' requirement is fulfilled.
 
medicalauditor said:
Thank you! There is written communication from the referring physician on file, but like I said, it is standard referral documentation. Nowhere in the referral does it state that it is a consultation request. It is hard for me to establish that this was intended to be a transfer of care because this is a recent visit and follow-up appointments have not happened yet. The prior auth says that 1 visit was approved. Finally, I understand that sharing the chart note with a physician in a large group is sufficient to fulfill the "written report" requirement, but what if the referring physician is not in the group with the consultant and is an external physician? I don't know if an external physician can access the consultant's EMR, but I presume not. As you can see, all this is making it challenging for me to establish if this was or was not an actual consultation and if it was, then whether the 'written report' requirement is fulfilled.
Click to expand...
From what you are describing, it doesn't sound like it would meet the requirements to be billed as a consult. If you can't validate that the report was actually sent back, it's also a little fishy. That sounds like a template/macro that is in every note.
 
amyjph said:
From what you are describing, it doesn't sound like it would meet the requirements to be billed as a consult. If you can't validate that the report was actually sent back, it's also a little fishy. That sounds like a template/macro that is in every note.
Click to expand...
I agree. I definitely looks like a template. I reviewed some more "consults" after I posted this, and for some of them, the referral clearly states that the PCP is sending over the patient to the derm for providing care. These were also billed as consultations, and the same templated note is in the chart notes. So now I know how I want to deal with this audit. Thank you so much for your assistance with this and all the great links you provided. Much appreciated :)
 
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