(Documented) Intent Matters for Consults

By G.J. Verhovshek, MA, CPC

“Remember the ‘Three Rs’ for Payers Accepting Consults” (June 2013, pages 26-29) generated more than the usual number of reader responses, and a few readers took issue with my insistence that what matters most when coding for consultations are a documented request, reason, and report. Specifically, they suggested what mattered most was intent: That is, did Provider A intend for Provider B to examine the patient and provide advice or opinion, or did Provider A merely refer the patient to Provider B for care?

Great point! I totally agree.

Let’s Revisit Guidance

Several years ago, writing about consultations (“Consult or Not? Here’s How to Know for Sure,” May 2009, pages 20-22), I called provider intent the “crucial fourth factor” (after request, reason, and report) that defines codes 99241-99245 and 99251-99255:

“A consulting physician may perform diagnostic testing or initiate treatment as part of a consultation service … 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 few months later (“Expel Consultation Code Worries,” August 2009, pages 40-41), I revisited the same theme:

“The first question to consider when deciding if a medically necessary service may be classified as a consultation is, ‘Was the referring physician asking for an opinion or advice so he could continue to treat the patient?’ If not, the service can’t be a consult, regardless of whatever documentation requirements the service might meet.”

Intent really does matter. A lot. As one reader wrote, “I think if everyone focused more on the intent of that visit, rather than having those three Rs dictated into a note, there would be far less coding confusion and misreporting.”

Be Sure Intent Is Explicit

As coders, the only evidence we have of provider intent is in the documentation. We’re not allowed to infer anything (We all know it by heart: Not documented = Not done.). And that’s precisely why the consultation request is so important: It establishes definitively that Provider A is asking Provider B for advice or opinion, and not simply giving a referral. The purpose of the request is to make the intent of the visit explicit.

Consider a hypothetical, but common scenario. Provider A says to a patient, “You should see Provider B about this issue.” The patient calls Provider B’s office and says, “Provider A says I should see you.” Provider B’s office (which will be billing the service) has an immediate responsibility to clarify the intent of the upcoming visit. Is it a consult or a referral? The answer matters not just from a documentation, coding, and billing point of view; it also affects patient care.

A standard consult sheet sent to the “requesting” provider’s office allows for clarity, making the intent of the visit explicit. You might even offer two options, asking Provider A to check one, and to sign, date, and return the form.

Likewise, the consulting physician must document the service precisely. If all that sounds like a lot of trouble, well … there’s a reason consultations reimburse at a higher rate than “regular” outpatient or inpatient visits. They’re more work, and ongoing communication between the requesting and consulting providers is part of the deal.

Be Leary of 
Consult Code Abuse

There’s no doubt consultation codes have been (and continue to be) abused, sometimes out of ignorance of the guidelines, sometimes purposefully. In 2006, the Office of Inspector General (OIG) released a report, “Consultations in Medicare: Coding and Reimbursement,” claiming that as many as 75 percent of services billed as consultations and allowed by Medicare in 2001 did not meet program requirements. The Centers for Medicare & Medicaid Services (CMS) famously stopped recognizing consultation codes 99241-99245 and 99251-99255 on Jan. 1, 2010, largely because the agency felt the codes were so often misapplied.

And over the years, I’ve heard anecdotally from many coders with providers who “seem to want to code a consult for eve-rything.” The common scenario involves a specialist who bills as a consult every patient sent from a primary care provider. I’ve seen this personally.

I’m an avid bicyclist, but I’ve had my share of accidents. Several years ago, I fell headfirst over the handlebars at 25 mph (An “endo”). A trip to the emergency department (ED) confirmed I hadn’t scrambled my brain (Thank you helmet!), but I did break my nose in several places and earned a few very nasty facial lacerations. The ED physician recommended I see a plastic surgeon to repair the damage, which I did. When I received a bill for the initial visit, I noticed that the plastic surgeon had billed a consult. Of course, the ED physician had no intention to treat me after I left the ED. He referred me to the surgeon for treatment, not for opinion or advice. It was a clear-cut transfer of care, and any auditor reviewing the case would have recognized it as such.

In some cases, a consulting provider may take over the patient’s care subsequent to billing a (legitimate) consultation service. As a rule, however, the requesting provider should be expected to act on the opinion or advice of the consulting provider. It’s inappropriate to bill a consultation simply because the patient arrives at the suggestion of another provider.

Any provider who routinely bills consults should consider very carefully whether the services are really consults, or are in fact referrals or transfers of care.

  • Is there a signed request making the intent of the requesting/referring provider clear?
  • Did the consulting provider report back to the requesting provider with advice and opinion?
  • Is the documentation clear enough that an objective third party (e.g., an auditor) would agree?

A “no” to any of these questions means you shouldn’t report a consultation.

Provider intent absolutely matters. In my opinion, that’s precisely why it’s so important for the intent to be made explicit in the form of a request, signed and dated by the requesting provider.


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


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