Consult or Not

Here’s How to Know for Sure

By G.J. Verhovshek, MA, CPC

In 2006, the Office of Inspector General (OIG) released the report “Consultations in Medicare: Coding and Reimbursement,” claiming as many as 75 percent of services billed as consultations and allowed by Medicare in 2001 did not meet all applicable program requirements. Even prior to the report’s release, consults were a fixture in the OIG’s yearly Work Plan. Today—three years after the OIG called for greater education on the reporting requirements for CPT® codes 99241-99255—proper consultation services reporting remains a consistent source of confusion for providers, payers, and coders alike.

Evaluation and Management – CEMC

CPT® defines a consultation as “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.” To substantiate a consultation service, documentation must include three elements: a request, a reason, and a report. An equally crucial fourth factor is intent. Often, reporting a consultation code for a given service comes down to honestly answering the question, “What did physician ‘A’ hope to accomplish by sending the patient to physician ‘B?’”

The Request

A consultation request typically comes from a physician who is seeking the opinion and advice (report) of another physician, usually a specialist, on how best to treat a patient with a specific problem (reason). A consultation request may also come from a “qualified” non-physician practitioner (NPP)—such as a physician assistant, nurse practitioner, etc.—who is acting within the scope of practice and licensure requirements for NPPs in the state in which she practices, according to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Claims Processing Manual, chapter 12, section 30.6.10.A. Always research your particular state and payer requirements before reporting an NPP-requested service as a consultation because state and payer guidelines vary.

Important: The consultation request must appear in writing; a verbal consultation request alone does not meet documentation requirements. CMS regulations specify, “The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.F).

Patients or a patient’s family may not request a consultation. An evaluation and management (E/M) service “not requested by a physician or other appropriate source … is not reported using the consultation codes but may be reported using the office visit, home service or domiciliary/rest home care codes,” according to CPT® guidelines. This means, for instance, if a patient requests a second opinion on a diagnosis, the physician would report the service not as a consult, but as a standard inpatient or outpatient E/M visit, as appropriate and supported by documentation.

If a payer requests a physician provide a consultation service—for instance, for a second opinion prior to approving treatment—the physician should append modifier 32 Mandated services to the appropriate consultation code. This alerts the payer that the source of the consult was not another physician, but the payer itself. Medicare will not recognize modifier 32 for payment, nor will it pay for a second opinion evaluation to satisfy a third-party payer requirement (Medicare Claims Processing Manual, chapter 12, section 30.6.10.D).

The Reason

Written documentation must reflect why (the signs and symptoms the patient displays, etc.) the consult was requested. Medicare guidelines stress, “The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of car” according to the manual.

The Report

“After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician,” CMS guidelines require.

The report is not a thank you note to the requesting physician for referring the patient, nor is it a courtesy copy of the history and physical. Rather, the report provides instruction to allow the requesting physician to continue treating the patient.

In most outpatient settings, the consulting physician’s report (like the consult request and reason) is a separate document sent from one physician to another. In the emergency department (ED) or other outpatient setting in which the medical record is shared between the requesting and consulting physicians (such as a large, multi-specialty group practice), the request, reason, and report may be a part of the shared record. Likewise, in an inpatient setting, the request, reason, and report may be part of the shared medical record, says the manual.

Intentions Matter

A consulting physician may perform diagnostic testing or initiate treatment as part of a consultation service (more on that to come), or may even take over the patient’s care at a later date, but the point of a consultation is always the same: With the consulting physician’s advice as a guide, the attending/requesting physician intends to continue to treat the patient. If the requesting physician intends for the consulting physician to assume immediate care of the patient’s condition, the service is not a consultation, but instead a referral or transfer of care.

A transfer of care occurs “when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.B).

For instance, a pulmonologist sees a patient at the primary-care physician’s (PCP) request. The consultation request specifies, “Patient wheezing indicates that she may suffer from asthma. Please provide additional workup and your opinion on treatment options.”

This service has a request and reason, and the PCP clarifies his wishes to continue to treat the patient for the possible asthma. If the pulmonologist responds with a written report outlining a care plan and possible treatment options, he has met all outpatient consultation requirements and may report 99241-99245, as appropriate to the documented service level.

In contrast, consider this example: An ED physician treats a patient for a sprained ankle (845.01 Sprains and strains deltoid (ligament), ankle) by strapping (29540 Strapping; ankle and/or foot). The ED physician discharges the patient and advises him to visit an orthopedic clinic for follow-up. In this case, the orthopedist would not report a consult upon seeing the patient because the ED physician isn’t really seeking the orthopedist’s advice or opinion.

When a physician assumes immediate responsibility for a patient’s care, you should report an appropriate inpatient or outpatient E/M service level. Do not report a consultation code to describe the visit—even if the service otherwise meets the consultation requirements.

A Consult Can Include Treatment

Regardless of whether the consulting physician initiates treatment, CPT® guidelines clarify that payers should recognize a consultation service as long as the visit meets all consultation criteria and no care transfer occurs. Medicare rules confirm this advice with the statement, “Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.”

For example, a patient visits his PCP with chest pains consistent with unstable angina (411.1 Intermediate coronary syndrome). The PCP requests a consultation from a cardiologist to evaluate the patient and to provide treatment recommendations. The cardiologist performs a diagnostic heart catheter (for instance, 93510 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous), which showed minimal disease, writes a prescription for the patient, and prepares a letter with findings and recommendations for ongoing care. Although the cardiologist initiated care, the service meets all the consultation requirements and may be reported as such.

Group or Specialty Physicians Can Request Consults

CMS guidelines allow for same-specialty or same-practice consultations “when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.” CMS does warn, however, “A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.E).

For example, an ear, nose and throat (ENT) specialist sees a patient who complains of left-side-only hearing loss (388.40 Abnormal auditory perception, unspecified). The ENT suspects an acoustic neuroma due to the single-sided nature of the problem, and requests a consultation with a neuro-otologist in the same practice. As long as the service meets all the consult requirements (request, reason, and report), the neuro-otologist may report the service with the appropriate outpatient consultation service code (99241-99245).

Because same-specialty/practice consultations provide an opportunity for abuse, requesting physicians should clarify in the documentation that the same-specialty/practice consulting physician truly has a skill set the requester does not have. Otherwise, the payer may view such consultation claims as an abusive or fraudulent attempt to gain payment for an unwarranted service.

Remember: If the specialist knows he or she does not have the skills or expertise to treat the problem, and is asking the subspecialist to handle that portion of the patient’s condition, then you cannot bill a consult for the subspecialist’s services. Rather, the service represents a transfer of care, and you would report the code for the appropriate inpatient or outpatient E/M service level.

In an upcoming issue, we’ll report on general reporting guidelines and code selection for inpatient and outpatient consultation services.

G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.

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