August 1999 Bulletin

Be careful in coding consult or referral

Difference is a matter of documentation, services provided, wording of invitation to participate

By Wanda L. Adams

The difference between a consult and a referral is more than their dollar values. It is a matter of documentation, services provided and how your invitation to participate in a patient's care is worded. While the definition of a consult has long been a highly controversial subject, as of October 1998 the correct use of consult codes and the necessary documentation requirements have been defined in the Medicare Carriers Manual (MCM), Section 15506,.

A consult is defined by the American Medical Association and Health Care Financing Administration as a request for opinion and/or advice. While a consultant may initiate diagnosis or therapeutic services, the documentation should indicate that a recommended course of action was given to the attending physician and the consultant is initiating treatment at his request. Note: The word "treatment" is not part of the definition of a consult. A consult is a single event to evaluate and offer advice on patient care.

Consult: Advise me how to treat my patient.

Referral: Here is my patient, treat him/her as you think best.

The task to define the type of services provided by another physician is the responsibility of the requesting physician. The requesting physician has the right to decide who will treat the patient, based on the submitted advice or opinion with the transfer of care documented in the patient's record.

The term "orthopaedic consult" does not in itself clarify what services you are being asked to provide when you receive a call from the floor nurse or an emergency department. Actual code selection must be based on the documented reason you were asked to see the patient. For example, you receive a request for an orthopaedic consult in the ER for a patient with a fracture. What are you being asked to do?

I have a patient with a broken arm, tell me how to repair it (consult) or

I have a patient with a broken arm, fix it (referral).

The attending or requesting physician must document in the patient's medical record the request for the consult and medical necessity as to why a consultation is needed. The consulting physician must provide a written report to the requesting physician advising on care or treatment or offering an opinion on patient care. In the hospital setting, the request may be documented in the requesting physician's plan of treatment or progress note as an order in the record, or a specifically written request for consult. In the office, the requirement can be met by a specific reference to the request. Although CPT does not specify what form the communication must take, in the case of a phone call or verbal communication of any type, both physicians should document the discussion in their records.

Correct coding is based on how the request for service was documented.

When you receive a request that states "evaluate and treat as needed" consider this as a request for you to assume the treatment of the patient. To report these services, use the out patient or office service codes 99201-99215, based on new or established patient criteria.

In an audit, your services may be reduced to office or hospital visits when using the following phrases:

Other problem phrases that convey the understanding that you are assuming patient care includes "thank you for referring the patient to me," "I will continue to see the patient tomorrow," "I will follow the patient with you," etc.

Wanda L. Adams is president of Adams Physician Advisory Incorporated in Festus, Mo., and founder and past president of the St. Louis Chapter of the American Academy of Professional Coders (AAPC). She also is a member of the AAPC National Advisory Board.

Question: One of our orthopaedic surgeons became interested in initiating billing for the professional component of X-rays. Our practice has never done this. Is this our oversight?

Answer: The only time that a physician can bill for the professional component is if he renders the full description of this service. He must read the X-rays and report the findings in a separate signed document. X-ray codes have a global aspect; that means that they have both technical and professional component already assigned to it. If the X-rays are taken in your facility, and you are billing the global code (without any modifiers) you are already billing the professional component and should be meeting those requirements. If patients bring X-rays into your office for their appointment with the physician and the physician reads these and discussed it with the patient, that is part of the E&M service and you are not usually allowed to charge for the professional component of the X-rays brought to your office. HCFA has stated that there should only be one professional component paid for X-rays.

Margie Scalley Vaught, CPC, is an office manager and coding specialist for Daniel L. Hiersche, MD, an orthopaedic surgeon, Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

Home Previous Page