Confused over consultation codes?
Carefully review guidelines
By Robert H. Haralson III, MD, and reviewed by Margie S. Vaught, CPC, CCS-P, MCS-P
Over the last few years there has been a lot of confusion over the proper coding and documentation for consultations. The confusion has been made worse by several articles in the American Medical Associations (AMA) CPT Advisor and misguided advice by well-meaning consultants.
The Centers for Medicare and Medicaid Services (CMS), formerly called the Health Care Financing Administration, had further confused the situation by delaying publication of definitive guidelines and by the varying interpretations of different local carrier medical directors. However, after discussions at the CPT Editorial Panel with CMS representatives, we have some reasonable and interpretable guidelines. See Medicare Carriers Manual Section 15506.
The guidelines suggest that anytime a physician sees a patient at the request of another physician or other qualified health care provider, the visit may be a consultation.
There are four considerations for the visit to qualify as a consultation:
The following advice is based on interpretation of the guidelines and discussions with the AMA CPT staff and CPT Editorial Panel members from CMS:
The requesting physician must be seeking advicenot transferring care. The CPT and CMS guidelines have always stated that a physician may order laboratory tests and/or institute treatment at the time of a consultation. Therefore, if an internist admits a patient with a broken hip and asks the orthopaedic surgeon to see the patient, the orthopaedist may order X-rays and even take the patient to surgery and the visit may still be a consultation.
Likewise, if an emergency room physician asks an orthopaedist to see a patient with back painin the emergency departmentthe orthopaedist may institute treatment and the visit may still be a consultation.
What cannot be coded as a consultation is the situation in which the referring physician arranges for the receiving physician to take over part or all of the care prior to the receiving physician seeing the patient.
One confusing statement in the CPT guidelines notes that if a consulting physician assumed part or all of the care of the patient that it was no longer a consultation.
What CPT states
CPT states that if the receiving physician assumes part or all of the care of the patient, the subsequent visits must not be coded as a consultationbut as subsequent outpatient or hospital care. Follow-up consultations would be appropriate only when there is a period of time between visits.
CPT and CMS outline two ways a physician can bill follow-up consultations. For instance, if you saw a patient in consultation, made recommendations and signed off and then were asked to see the patient because the treatment did not work, that may be a follow-up consultation. Another example would be a patient with back and leg pain for whom you ordered an MRI and the patient returns after the study with the confirmed diagnosis of a ruptured disc.
Document the request
There must be documentation in the patients record that the consultation was requested. There are several ways to accomplish this requirement. If the requesting physician sends a letter asking for the consultation, that will suffice.
Some coding consultants suggest consultation request slips be distributed to each of your requesting physicians and one should accompany the patient. CMS and CPT state that the receiving physician may insert that documentation into the record by stating something similar to, "I was asked to see this patient in consultation by Dr. X."
Document the level of visit
The level of the visit must be documented in the record. This is similar to all the documentation guidelines and in the case of consultations should be followed to the letter. Understand that there is no difference between a new and established patient where consultations are concerned.
In spite of all the controversy about documentation guidelines, until CMS does something else, we are still under the 1997 guidelines.
Document the request
There must be documentation that the findings of the consulting physician were communicated in writing to the requesting physician. This can be accomplished by sending the requesting physician a copy of the patients record and a "thank you" letter should also be included.
There was some advice earlier that this communication could be by phone, but the recently published guidelines require that it be in writing. Documentation in the medical record that a phone conversation took place may not always be sufficient.
Coding too many consultations can raise red flags
The problem with coding a large number of consultations is that the practice raises red flags to CMS carrier medical directors who are monitoring each physicians coding profile. Abnormal coding profiles are likely to bring on audits, so the physician must weigh the increased revenue from a consultation versus the possible consequences of an audit.
On the other hand, in my practice, we have several fellowship-trained and very specialized physicians and nearly every patient they see is at the request of another physician. If you submit large numbers of consultation codes, just be sure you follow these guidelines.
Robert H. Haralson III, MD, MBA, is the medical director of Southeastern Orthopaedics in Knoxville, Tenn. He is the CPT advisor for the Academic Orthopaedic Society and has taught courses on the use of AMA Guides, CPT, the use of computers in medicine and disability medicine. He can be reached at (865) 769-4532 or at email@example.com.
Margie S. Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders National Advisory Board. She can be reached at firstname.lastname@example.org