The Coding Sleuth 17
by Tara Conklin
The Case of the Confused Consultant
It seems the more I work this case, the more it keeps coming back around. Doctors are constantly getting confused when to code a consult, when is a consult a consult and not a referral, how to properly document a consult, what is required for a consult???
So many infernal questions that can baffle the even the most genius of medical minds. But fear not, The Coding Sleuth is here to crack the case (again) and shed some light on the subject.
When you think of a consult what comes to mind? A question and answers session perhaps? Well, Webster’s Dictionary defines a consult as “to have regards to, consider” and “to ask the advice or opinion of”. This second definition is probably the best description of what service a physician is performing during a consult. He is “rendering an opinion and/or his advice on the situation with a particular patient”. This is an important piece of information to understand because on many occasions a patient is sent to a physician for evaluation and treatment of a problem. However, in this situation the service is a “referral” and not a consultation. These two services can get confusing since a consulting physician can also initiate treatment of a patient. So, in order to clear up this issue we need to be clear on what constitutes a “true consult” as far as CPT Guidelines go.
Let's go sleuth out the clues.
The first place to look is, of course, in your CPT. Guidelines for coding and documenting consults have been provided just before the first set of consult codes 99241-99245.
The first paragraph states “a consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”
This paragraph tells us a few things. First it tells us the consulting physician is asked to provided an opinion or to manage a specific problem, such as an Oncologist being asked to manage a patient’s cancer. The Oncologist is usually asked to confirm a diagnosis of cancer first and then relay his findings and his opinion on the best course of action for treating the patient. The second thing it tells us is the request can be by either another physician OR an appropriate source. An appropriate source would include nurse practitioners, physician’s assistants, and psychiatrists. These appropriate sources may also provide consults when requested.
In the next paragraph, the CPT guidelines state “the consulting physicians may initiate diagnostic and/or therapeutic services at the time of the same or subsequent visit.” This is where the difference between our consult and our referral need clarification. Let’s take the example of two patients, Elvis Hipster and Letty Zepplin. Both patients see Dr. Makemwell as their primary care physician. On a particularly beautiful day in spring both patients come in to see Dr. Makemwell for a red swollen lump on the arm. Upon examination of Mr. Hipster, Dr. Makemwell feels the lump on Mr. Hipster's arm could be either an abscess or an infected inclusion cyst. Due to the size of the lump and the unsure diagnosis of the problem, Dr. Makemwell tells the patient he would like him to visit a general surgeon, Dr. Kutenso, for his opinion on the problem.
On his second patient, Ms. Letty Zepplin, Dr. Makemwell quickly determines she has an infected abscess that would benefit from a surgical drainage. Dr. Makewell tells her he will make an appointment with Dr. Kutenso to perform an incision and drainage on the abscess.
Both patients happen to get appointments with Dr. Kutenso on the same day (how coincidental is that?). First, Dr. Kutenso sees Mr. Hipster. He examines the lump on his arm and decides to take a needle biopsy of the site in order to better conclude the exact diagnosis. He makes a final determination and relays his findings or opinion back to Dr. Makemwell along with his opinion on the best way to proceed with proper care. Next Dr. Kutenso sees Ms. Zepplin. He takes a history and physical and schedules her for an incision and drainage the next afternoon at Happy Hospital.
The difference between these two patients' visits to Dr. Kutenso is that Dr. Makewell felt he needed another point of view or opinion for the problem with Elvis Hipster. With Ms. Zepplin, however, Dr. Makemwell was able to come to a definitive conclusion and sent her over to Dr. Kutenso to actually care and treat the problem. Even though in both visits Dr. Kutenso performed procedures and initiated treatment on both patients, the reason for their visits was completely different. One was a request for an opinion and best course of action and the other was simply a referral to treat.
Capeesh?
Let’s move on to our CPT Guidelines again. The third paragraph provides the most important information for billing consultations. The information stated gives specific requirements that must be present in the documentation in order to substantiate a consult code. We call them the three R’s.
There are three (yes I mentioned that) requirements.
First a written or a verbal Request for a consult (opinion) may be made by a physician or other appropriate source (nurse practitioner) and documented in the patient's chart. If Dr. Makemwell called Dr. Kutenso on the phone and said “Hey, Frank. This is Ted. How was your golf game on Sunday? Really? That’s great. We’ll have to get together and play a few holes soon… sure sounds good. Say, the reason I’m calling is I have a nice patient of mine here, his name is Elvis Hipster, and he has what appears to be an abscess on his left arm. But it also looks like he may have an infected inclusion cyst. Would you mind looking at it? Great, thanks. I’ll send him over tomorrow and look forward to hearing from you.”
In this situation, Dr. Makenwell called Dr. Kutenso to ask for his opinion. Therefore, both physicians need to document in their perspective charts for this patient that this verbal request was done. If the request had been in written form, such as a nice letter or a script, a copy of the document should also be kept in both charts.
This establishes the first R – the Request.
The second requirement is the consulting physician’s opinion. Hold on Slick - I know there isn’t an R in this step but you’re getting ahead of yourself. or at least me. Slow down. The consulting physician Renders his opinion. See our second R - if you would have given me a chance, Quickdraw. His opinion can be in the form of his history, exam and medical decision making, his office note. The most effective way to show a request was made is to start the documentation with a simple phrase such as “Mr. Hipster has been sent to me by request of Dr. Makemwell for consultation of / my opinion (either will work) of a.....”
A simple sentence such as this is quick to the point and establishes the purpose of the visit.
The third R can get a little tricky and is often the step that gets missed. Once the opinion has been made the consultants findings must be communicated by a written Report back to the requesting physicians. Now there are two ways this can be accomplished in a clear and concise manner in order to ensure this third step has been made. The first is for the consultant to dictate a letter of his findings and any treatment or diagnosis option back to the requesting doctor. This is a surefire way to meet this step… not too mention very professional. However, unless you have a doctor that likes to write or talk or is meticulous about dictating absolutely everything down, most physicians don’t take the time to do this. It’s time consuming.
The second way is to include a closing sentence at the end of the H&P showing the effort was put forth to send a copy of the documentation back to the requesting physician. For example, at the end of Dr. Kutenso’s office visit he could make the following statement, “Thank you, Dr. Makenwell, for consulting me on this very nice gentleman. A copy of this documentation will be sent to your office. I look forward to working with you on the care of this patient.” At the end of the document a cc. line to all necessary parties should also be added.
Make NOTE: A CC. LINE ALONE IS NOT SUFFICIENT DOCUMENTATION TO MEET THE THIRD CONSULT REQUIREMENT.
Documentation should clearly show the consulting physician acknowledges his findings are required to be sent back to the requesting physician and an effort to do so was made.
You can bet your boots an auditor is going to look for crystal-clear proof that a consulting physician understands the three R requirements and is putting forth the effort to ensure all requirements are met.
Now that we understand the requirements of a consult, what happens afterwards? Well, my friend, this all depends on the purpose of future visits. A consult is only billed on the initial visit of a particular problem. In the outpatient setting the consult is billed on the first visit. All subsequent visits related to the same problem should be billed with established patient office visit codes 99211-99215. A patient may be known to a consulting physician, perhaps for a condition in the past. But if the same patient is sent for consultation back to the physician for a new problem, then the consulting physician should bill a consult code and follow the requirements for a consult.
Inpatient things are a little different. Since only the admitting physician can bill from the 99221-99223 code set iInitial inpatient care) all other physicians must use either an inpatient consult code 99251-99255 or follow-up hospital codes 99231-99233. If a physician is asked to see an inpatient by the admitting physician in consult for either a new or established problem, the consulting physician should bill a code from 99251-99255 on the first day he sees the patient during a particular admission stay. If the same patient is discharged and admitted at a later date and the same consulting physician is asked to consult on that patient for the same problem he followed in the last admit, the consulting physician would again bill a consult code from 99251-99255 on the first day he sees the patient during the new admit. A new consult is billed for each separate admission by a physician following a condition unrelated to the reason for admit. For example, a patient is admitted with gallstones by Dr. Howyaben, but this patient has also been followed by Dr. Hapihart for congestive heart failure for the past two years. Dr. Howyaben asks Dr. Hapihart to follow the patient’s CHF during this admission and consult with him on how the CHF may effect treatment of the gallstones. Even though the CHF is known to Dr. Hapihart and he is the treating physician for this condition, he is not the admitting physician during this admission; he is only “consulting” with the admitting physician. Therefore, on his first visit with the patient at the hospital Dr. Hapihart will bill 99251-99255 appropriately. All subsequent visits will be billed using inpatient follow-up codes 99231-99233 respectively.
Lastly, consult codes can only be reported if the consult has been requested by a physician. Consults requested by patients should be billed using the appropriate new or established outpatient codes (note this rule is effective Jan 1, 2006 with the deletion of codes 99271-99275).
Consultations are common practice. Follow up with your physicians, educate them and help them establish healthy habits when accepting and performing consults in their practice. Be persistent and this case will finally stay cracked.
Until next time Gumshoes! Keep coding.
--Tara