Anesthesia Coding Alert

Follow these 3 tips to know when to report them Medicare is increasing its audits of consults versus referrals, which means you need to be extra sure you're correctly documenting and coding cases. Read on for three  great tips on knowing when you can legitimately bill a consult instead of a referral. Tip 1: Distinguish Between Consults and Referrals For accurate consultation coding, you need to start with learning some basic definitions. Medicare defines a consult as a patient encounter that includes:

a formal request from another physician or provider for a second physician to provide an opinion
documentation of the request in the patient's chart, stating the reason for the patient's visit and what opinion is sought
formal written communication back to the requesting physician concerning the patient's visit and status (not just a copy of the second physician's notes).

Many coders are familiar with this list, or some variation of it, known as the Three R's (request, render and report) of consultations. The confusion lies in Medicare's rule regarding transfer of care or "taking over the patient's treatment," as well as basic terminology crossover.

"The true definition of a consult is rendering an opinion," says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. "If the physician needs to initiate diagnostic and/or therapeutic services at the same visit or at a subsequent visit, that's OK and it's still a consult."

"When coding professionals refer to 'referrals,' we're not talking about managed care," says Jann Lienhard, CPC, a coding consultant with SM/art Performance in Philadelphia. "We're talking about consults and referrals based on CPT4. The onset of managed care and the use of the same terminology has led to mass confusion in the entire industry."

Many pain management specialists believe they should always bill "consults" because they aren't the patient's primary physician. But if the "sending" physician's intent is to "transfer patient care" for that particular problem, the pain management specialist (in this case) becomes the treating or primary physician. And that means you report the service as a referral, not a consult.

An example: Many pain management patients are referred to a specialist for treatment. Referring (sending) physicians often use phrases such as "Evaluate and treat," "Refer to Dr. X for low back pain," or "Consult and treat" in their paperwork. These are all new patient referrals because the pain physician is being asked to perform some type of treatment -- rather than simply offer an opinion on the case -- and should be billed as such. Choose the appropriate E/M code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) for the visit, depending on the level of service documented and [...]