Remember the “Three Rs” for Payers Accepting Consults

Proper documentation is a must for reimbursement of 99241–99245, 99251–99255.

By G.J. Verhovshek, MA, CPC

Medicare payers haven’t accepted claims for either outpatient (99241-99245) or inpatient (99251-99255) consultations since Jan. 1, 2010. Private payers, however, may still pay for consultation services as long as those services are supported by the “three Rs” of consult documentation: Request, Reason, and Report.

Evaluation and Management – CEMC

First R: Request

Every consult must begin with a request. CPT® specifies, “The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source.”

Because the consulting provider bills the service, it’s in his or her best interest to document the request as part of the patient record. For example, a consulting physician might begin the record, “Ms. Jones is here today at the request of her primary care provider, Dr. Smith, for a consultation to evaluate condition X.” Specify that the visit is “consult” (not, for instance, a “referral,” which may signify to the payer a transfer of care request rather than a request for consultation). If possible, ask the requesting provider to put it in writing (email, fax, a note sent with the patient, etc.) and to make that part of the record, too. In the inpatient setting, the request may be part of the shared patient record.

Services provided solely at the request of a patient, family member, or non-clinical caregiver do not qualify as consultations. An appropriate source for a consult request can include physicians or other individuals who can act on the advice/information the consulting physician provides. Generally speaking, qualified non-physician practitioners (NPP) can request and provide consults (99241-99255) as long as the services are within their scope of practice, as defined by their state, credentialing body(ies), and facility. To be certain, consult your payers’ guidelines for their rules on whether NPPs may provide and/or request consultations.

Second R: Reason

The requesting provider must also state a specific reason (i.e., patient complaint or condition) to justify the need for a consultation. For example, if the patient’s primary care physician wants a specialist to evaluate a patient due to a suspicious breast lump, she should state this reason explicitly in the request for consult.

Third R: Report

Lastly, and perhaps most importantly, the consulting provider must render his or her opinion and return a written report of his findings and treatment suggestions to the requesting provider. The entire reason for the service, after all, is so the consulting physician can give his opinion and advice to the requesting provider. Without a report back to the requesting provider, a consultation hasn’t occurred.

Consults Require Three of Three Key Components

If a request, reason, and report are sufficiently documented, you may submit claims for consultation services to (non-Medicare) payers who accept them. Select 99241-99245 for consultations provided in the physician’s office, or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department (ED).

Select 99251-99255 for consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting. An individual provider may report only one inpatient consult per inpatient stay. For follow-up visits by the same provider subsequent to a consultation, but during the same inpatient stay, report subsequent care codes (e.g., 99231-99233 Subsequent hospital care …).

Both the outpatient and inpatient codes apply for new and established patients and both types of consultation services require you to meet all three key components (history, exam, and medical decision-making (MDM)) to report a given level of service. Practically speaking, the “lowest” of the three components always determines the level of service reported.

For example, a general surgeon is called to the ED to see a 55-year-old (non-Medicare) patient for assessment of abdominal distention, nausea, and vomiting. The request and reason are documented in the medical record. The surgeon renders an opinion and reports this to the requesting physician. The surgeon documents a detailed history (HPI = 4, ROS = 2-9 systems, and PFSH = 1) and detailed examination (2-7 organ systems and/or body areas), with MDM of moderate complexity (diagnosis = 2, data = 2, and risk = low; you must meet two of three). Because the service occurs in the outpatient setting, the proper coding is 99243 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity….

In a second example, the managing physician requests that a specialist provide a consultation for a hospital inpatient recovering from surgery and complaining of (unrelated) abdominal pain. The specialist meets with the patient and performs a full history and exam. She prepares a report of her findings and shares these with the requesting physician. When preparing the claim for a payer who recognizes consultation services, report an initial inpatient consult (e.g., 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity). If the same specialist provides additional services to the same patient during the same inpatient stay, report the subsequent services using the 99231-99233, as determined by the level of documentation.

Time Can Become the Determining Factor

If more than 50 percent of the consultation visit is spent in counseling or coordination of care, you may report the consultation using time as the primary component (rather than history, exam, and MDM). Note that the outpatient codes (99241-99245) include only face-to-face time with the patient; whereas, inpatient codes (99251-99255) include face-to-face time, as well as time spent on the hospital floor on the patient’s behalf.


What Makes a Consult Unique?

CPT® defines a consultation as “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for care of a specific condition or problem.”

In other words, the service involves three individuals: a requesting provider, a consulting provider, and a patient.

The requesting provider asks the consulting provider to examine the patient and give his opinion on a patient’s specified treatment and/or condition. The point of the service is that the consulting provider has some knowledge, training, or expertise the requesting provider does not have, making the consulting provider better able to evaluate the patient and recommend treatment for a particular condition or complaint. Generally, the consulting provider will be a specialist or subspecialist, or the requesting and consulting providers will be of different specialties/subspecialties.

The consulting provider may report a consultation code (for non-Medicare payers who accept consultation codes) even if he or she performs diagnostic testing, begins treatment, or—subsequent to completing the consultation service—accepts responsibility for the patient’s care. What matters most is that the “three Rs” (Request, Reason, and Report) are properly documented.

In an upcoming issue of AAPC Cutting Edge, we’ll cover how to report consultation services for Medicare payers.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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