Wiki Consultation with Same day Procedure

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Patients comes into the office referred from his PCP for hemorrhoids. Provider consults the patients situation and decides to remove the hemorrhoid at this visit - he has now asked to bill for the consult with a 25 mod and the procedure for removal hemorrhoid- there is only 1 dx documented - Can we still bill for the consult since the pt had the hemorrhoid removed on this date or would this be transfer of care? Should we only be billing for the hemorrhoid removal? However, we have the "3r's" referrral, render and then the dr will provider the report after the hemorrhoid removal.

Please advise
 
Yes you can bill for it. You are not required to have a different dx to bill w/ a mod 25 although it's up the ins on whether or not they will reimburse. Lately we have had to appeal BCBS because they have been denying when we've done this. Any chance this pt had rectal pain or bleeding? You could use this as the primary dx.
 
Not a consult

This is a transfer of care. Your doctor is taking care of the problem completely - by removing it. If your doctor sent back to the PCP and said 'recommend hemorrhoid removal', and then the PCP called back and said 'ok fine go ahead take them out' - then that would be a consult. The PCP didn't play any role in the treatment of the problem, he didn't decide any of the management options because the consultant took it upon himself. Which is fine, it's just not a consult.
So, if the patient is new, use 99201-99205. If established, use 99211-99215.
Also bill the removal, and use your mod 25 as appropriate on the E/M.
 
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You CAN initiate treatment with a consult

AR,
I respectfully disagree that just because treatment was initiated that makes the visit a transfer of care.

CPT guidelines (2008 CPT, Professional Edition, pg 14) clearly state:
A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. (emphasis added by FTB)

That being said ... what makes ME think this may not be a consult, is that the poster started the scenario with: Patient comes into the office referred from his PCP for hemorrhoids.

It all depends on the documentation. There is a difference between "referral" and "request." But I still see people use those words interchangeably.
A physician refers a patient to another physician for treatment. (transfer of care)
A physician requests a consult from another physician regarding a patient problem. (consultation)

Back to the original question .. I agree with abenson that you can initiate treatment (or diagnostic tests) and append a -25 (or -57) modifier to the E/M if it was performed the same date of service.

F Tessa Bartels, CPC, CPC-E/M
 
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I agree w/ftessa, the consultant can begin treatment on the same day.

If the patient is referred on an "insurance referral" form, check the wording in the comment box, sometimes if the staff is coding savvy, they will include "consultation for...." in the reason for visit section. Otherwise, the referring physician should write "consultation for....." on his letterhead or an rx slip.
 
not a consult

FTessaBartels said:
AR,
I respectfully disagree that just because treatment was initiated that makes the visit a transfer of care.

CPT guidelines (2008 CPT, Professional Edition, pg 14) clearly state:
A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. (emphasis added by FTB)

That being said ... what makes ME think this may not be a consult, is that the poster started the scenario with: Patient comes into the office referred from his PCP for hemorrhoids.

It all depends on the documentation. There is a difference between "referral" and "request." But I still see people use those words interchangeably.
A physician refers a patient to another physician for treatment. (transfer of care)
A physician requests a consult from another physician regarding a patient problem. (consultation)

Back to the original question .. I agree with abenson that you can initiate treatment (or diagnostic tests) and append a -25 (or -57) modifier to the E/M if it was performed the same date of service.

F Tessa Bartels, CPC, CPC-E/M
Click to expand...

I have the same issues. I interpret the words "diagnostic and or therapeutic treatment" to mean tests and/or meds, not surgery. If the physician is taking it upon themselves to "treat the problem of hemorrhoids by excising them", then that would make it a new patient visit, not a consult. The question is: what was the intent? When my colorectal surgeons decide that they are going to excise the hemorrhoid, they usually admit the patient, because that surgery is a 90-day global. Now, if they decide that they are just going to do an RBL, that is done on a later date, and again, the doctor gets a new patient visit, because for the most part, they usually follow up w/ that doctor for a few visits.
 
abenson said:
Yes you can bill for it. You are not required to have a different dx to bill w/ a mod 25 although it's up the ins on whether or not they will reimburse. Lately we have had to appeal BCBS because they have been denying when we've done this. Any chance this pt had rectal pain or bleeding? You could use this as the primary dx.
Click to expand...


Abenson,
I recently went to a seminar called Managing Effective Changes in Coding and Compliance (AACP approved.) The instructor stated she had attended a conference where our local Excellence Blue Cross Blue Shield carrier was there and was advising on the use and misuse of modifier 25. This BCBS rep stated they audited 100 charts billed w/ mod 25 and 80% were in error. There criteria was:
-Did you perform and document the key components for a complaint or problem?
-Could the complaint or problem stand alone as a billable service?
-Is there a different diagnosis for this portion of the visit?
-If the diagnosis is the same, did you perform extra physician work that went above/beyond the typical pre- or postopertive work associated with this code?

Personally I am very confused on the whole subject of both mod 25 and consults. I attended a teleconference a few months ago that took the stance of a consult consists of the 3 R's and the requesting physician is asking for advise on how to treat the patient. The consulting physician does not treat he/she sends the patient back to the requesting physician and gives his/her advise.

I was also of the mind set that an E/M same day as minor surgery does not need a separate dx as long as documentation supports. But more and more carriers are disputing this belief. I read through all the threads and it sounds like there is alot of back and forth on both topics.

Melissa-CPC
 
Melissa,
Like I said in my original post, I agree that a lot of the carriers are denying right now because of the dx thing. We have even had to appeal based on it, however I have documention from BCBS themselves stating that it's not needed. I did ask if the patient had any other complaints.
Any yes, the modifier is over used which is why it's on the OIG's watch list every year.
So what would you bill, just the hemorrhoid removal and no exam? Don't you think the dr. has to do some form of exam to determine that the removal is necessary. He doesn't know if they are internal, external or thrombosed.
 
I do think our doctors should be paid for the work they do. What about billing New patient visit and hemorrhoidectomy? I guess I was just saying I don't know if it's right with all the talk back and forth on what constitutes a consult.
Melissa-CPC
 
We encounter this scenario all the time. We bill it both ways depending on the referral/request documentation. If a PCP sends the patient for a "consultation" or "consultation & treat." we will bill appropriate 99241-5 code w/mod 25/57 and appropriate hemorr removal code. We do get paid even from BCBS. Yes, sometimes we have to fight and once in a blue moon we lose (usually b/c bad MD note). I have my MDs dictate a consult note totally seperate from the procedure note. This helps the "oh so bright" ins company reviewers see that 2 totally services were rendered. If the notes for the services are merged it is very hard to fight. We also ask the ins company if we should have the patients come back on a different day at the inconveinence of the patient so our MD can be reimbursed for the services rendered. Most of the time the ins backs down and we receive payment. Hope this helps!

Anna Barnes, CPC, CGSCS
 
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