Wiki Consults

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KoBee

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I still get a bit confused on Consults vs Referral.

I think our providers get confused themselves, I find myself at times trying to find the easiest way to explain the difference.

If the consulting provider puts an order for the patient to come back and see them, that is not help constitute a consultation code CPT 99242-45, correct? If consulting provider would want the patient to return, shouldn't the consulting provider report this back to the requesting physician and let the requesting physician put in a new order as a referral this time back to the consulting provider?

Help :/

Example:
PCP (requesting) order to see patient Ped gastro
Ped gastro (consulting) sees patient and treats with diagnostic test/labs, request patient to come back and see them by putting an order (authorization w/payer) to see them again.
 
The following long description from Encoder Pro may help you clear this up for yourself and your providers.

Office or other outpatient consultation service codes describe encounters where another qualified clinician's advice or opinion regarding diagnosis and treatment is rendered at the request of the primary treating provider. Consultations may also be requested by another appropriate source (e.g., a third-party payer may request a second opinion). The request for a consultation must be documented in the medical record, as well as a written report of the consultation findings. During the course of a consultation, diagnostic or therapeutic services may be initiated at the same encounter or at a follow-up visit.​

The important things to remember with consults are the 3 Rs:
  • Request from the treating provider (or a 3rd party such as an insurance company)
  • Reason the requesting provider must state a specific reason for the consult
  • Report from the consulting provider needs to be written with the consultant's opinion and the report needs to be sent back to the requesting provider.
Another tip to remember is that if the patient and/or family requested the consult you cannot bill with a consult CPT code 99242-245.

Here is a help, if a bit old, AAPC blog post link regarding billing for consults Remember the 3 Rs for Payers Accepting Consults.

I hope this helps clear things up for you and your providers.
 
For years, consultation codes were misunderstood, overused, and abused. I believe a large portion of this is simply because what a clinician calls a consult is NOT the coding definition of consult.
In your example, what seems to be missing is a report from the peds GI back to PCP.
Don't forget many payors have followed Medicare's policy and no longer recognize consult codes. I think we are down to just 2 payors that will accept them. We were getting so many denials that we don't even bother using consult codes anymore. It's more work for the coder to ensure the 3 Rs are met, then also check if the carrier accepts them.
 
I'm looking for help/ reassurance that I'm in the right to fight my personal bill. Background - I saw Maternal Fetal Medicine in 2022 for my first pregnancy. Saw them again recently for a 2nd pregnancy and it's still within the 3 year time frame. To me this should have been coded as an established office visit. I sent a message to the provider/billing dept and they are responding back with because there is a new dx from the last time I saw them and a referral from OB that it justifies a consult code.... am I correct in fighting this? Side note: I have a commercial insurance policy.
 
ambakken12 said:
I'm looking for help/ reassurance that I'm in the right to fight my personal bill. Background - I saw Maternal Fetal Medicine in 2022 for my first pregnancy. Saw them again recently for a 2nd pregnancy and it's still within the 3 year time frame. To me this should have been coded as an established office visit. I sent a message to the provider/billing dept and they are responding back with because there is a new dx from the last time I saw them and a referral from OB that it justifies a consult code.... am I correct in fighting this? Side note: I have a commercial insurance policy.
Click to expand...
Who requested the "consult" that the provider billed? Did it meet the criteria CPT for what is considered an actual consult as outlined below?
CBLENNIE said:
The important things to remember with consults are the 3 Rs:
  • Request from the treating provider (or a 3rd party such as an insurance company)
  • Reason the requesting provider must state a specific reason for the consult
  • Report from the consulting provider needs to be written with the consultant's opinion and the report needs to be sent back to the requesting provider.
Another tip to remember is that if the patient and/or family requested the consult you cannot bill with a consult CPT code 99242-99245.

Here is a help, if a bit old, AAPC blog post link regarding billing for consults Remember the 3 Rs for Payers Accepting Consults.
Click to expand...

If they did bill an OP consult code 99242-99245 but the 3 Rs criteria are not met then, your instinct that this isn't a consult appears to be correct. If that is the case, as you stated they should've billed an established OP/office E&M 99211-99215.

If you have access to your medical records through an online patient portal I would review the complete chart note for the recent and past visits, if there aren't full notes in the portal and just a brief aftercare/visit summary, I would contact the provider's office and ask for a copy of your full medical record, so you can see what was documented for your first visit as well as your recent 2nd visit. Once you have a clear picture of what was documented for each visit, I would again follow up with the billing department with your proof that the visit was coded incorrectly, assuming it was.

If the billing department doesn't address your concerns, I would recommend contacting your insurance company and report the provider for possible FWA. Additionally, I would recommend contacting the provider's compliance officer and letting them know your concerns and that you've reported them to the insurance company.

Good luck!
 
ambakken12 said:
I'm looking for help/ reassurance that I'm in the right to fight my personal bill. Background - I saw Maternal Fetal Medicine in 2022 for my first pregnancy. Saw them again recently for a 2nd pregnancy and it's still within the 3 year time frame. To me this should have been coded as an established office visit. I sent a message to the provider/billing dept and they are responding back with because there is a new dx from the last time I saw them and a referral from OB that it justifies a consult code.... am I correct in fighting this? Side note: I have a commercial insurance policy.
Click to expand...
As stated above, if the 3 R's are not met, it is not a consult. Request, reason, report.
Does your insurance plan even pay for consultation codes The presence of a new diagnosis does not warrant a consultation code. The referral from the OB would count as a request. However, there must be a report back to the OB on your visit. Most times, MFM meets consult requirements if a request is made provided the payer actually covers consultation codes.

See example policies below:


Edited forgot to add. I request ALL medical records for myself and my family members and code everything myself. There are so many errors.
 
amyjph said:
As stated above, if the 3 R's are not met, it is not a consult. Request, reason, report.
Does your insurance plan even pay for consultation codes The presence of a new diagnosis does not warrant a consultation code. The referral from the OB would count as a request. However, there must be a report back to the OB on your visit. Most times, MFM meets consult requirements if a request is made provided the payer actually covers consultation codes.

See example policies below:


Edited forgot to add. I request ALL medical records for myself and my family members and code everything myself. There are so many errors.
Click to expand...
I looked at the OB note and she did refer me and the MFM's note does have a blurp about who referred and why and then there is the office visit. We use Epic so the referring provider sees the MFM note since it's within the same system. I guess I'm just still thrown for a loop, because why would I need to referred and consulted again as I saw the same MFM provider 2 years ago. My insurance is a Medica Plan.
 
If that is the case, they can bill a consult. It is not the same rules as new vs. established E/M. Provided Medica covers consults, they can do it.
It's a different pregnancy/reason/episode of care. MFM are one of the specialties where you would see a lot of consults. What you should not see is another consult code for the same pregnancy. So, it would be one per. If/when you follow up with the MFM provider for this pregnancy and same reason, it turns to established E/M. There can be other nuances to this too depending on the documentation and situation/payor.


Read the CPT guidelines at the beginning of the consult codes E/M section and the CPT descriptions of the codes. The new/established decision tree concept does not apply, there is one set of CPT (outpatient consult). The consult codes state, "...for a new or established patient...."

The same thinking could be applied in other cases. For example, a PCP asks a neurologist for a consult for a patient for LT arm numbness/pain. The neuro meets all the documentation requirements, the payor allows consults, and the neuro bills a consult. 6 months later, the same PCP asks the same neuro for a consult for the same patient but now it's for a totally different reason such as possible seizures. If the neuro meets all of the requirements/documentation they can bill another consult.
 
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