Cardiology Coding Alert

Differentiate between Consults and Referrals:

Reduce Risk of Audits with Correct Coding for Cardiology Consultations

The common usage of the word referral has thrown a cloud of ambivalence around coding for consults. To cut the confusion, the term referring physician should not be used when you really mean the physician who requested the consultation. In strict coding parlance, a referring physician actually turns over care to another doctor, rather than merely asking for advice.

Cardiologists are often called upon to consult with attending physicians; yet, choosing the correct evaluation and management (E/M) code for consults can be confusing. Is your service really a consult? Or a direct transfer of care? Choose the wrong answer and you could be targeted for an audit, warn cardiology coding experts.

Charging for a consult when you shouldnt is the mistake I see most often, says Jeanette Cost-Blubaugh, CPC, business office manager, Mid-Ohio Heart Clinic, Mansfield, OH and consultant for Corporate Medical Consulting.

But in order for your cardiology practice to bill correctly, you need to know these basics behind coding for consults.

1. Learning the basic definitions will help you distinguish between consults and transfers. An attending physician is responsible for providing the patients overall care. If the attending physician needs an opinion or advice regarding the treatment, diagnosis, or management of a specific problem, he or she then requests a consultation from another doctor.

Essentially, the attending physician is saying Take a look and tell me what you think about the problem and give me your opinion, but the overall care of the patient remains with me, says Susan Garrison, MPC, CPC, CPC-H, CPAR, president-elect of the American Academy of Professional Coders and senior manager at Hyatt, Imler, Ott, and Blount, a coding and billing consulting firm in Atlanta.

On the other hand, if the message the attending physician sends is You take over the care, that is a referral, or transfer of care, she points out.

A major difficulty in distinguishing between a consult and a referral occurs because the consultant -- the physician giving the advice or opinion -- can also perform diagnostic or therapeutic services in order to render an opinion, explain Plunket and Cost-Blubaugh.

Some coders feel that once the consulting physician initiates any kind of treatment, he or she is then no longer [merely] consulting [but instead has taken over the patient], but I dont agree with that, Cost-Blubaugh opines.

For example, perhaps the cardiologist needs to do a stress test or a catheterization in order to form his or her opinion, Plunket adds. It is not the presence or absence of these tests or procedures that indicates whether the new physician is taking over the care, Cost-Blubaugh maintains. Even if the consultant initiates care, if he or she reports the findings back to the requesting physician, it is a consultation. (For more tips to determine whether an episode is a true consultation, see the box below.)

Your determination of a consult should be based on these factors:

a. Are both the initiating doctors request and the consultants responding opinion documented in the medical record?

b. Did the consultant discuss his or her recommendations with the requesting physician?

c. If the consulting physician performed the diagnostic test or services in order to help render an opinion, was responsibility for patients care then returned to the requesting physician?

If the answer to the above three questions is yes, then the cardiologist has performed a consult, and you can bill using codes 99241-99263.

However, Cost-Blubaugh adds that subsequent visits to the consult would be billed using codes for established patient visits (99211-99215).

2. When not to code as a consult. If the answer to any of the above questions is no, youll need to select another E/M code outside of the consultation category.

If the cardiologist assumes responsibility for all or a portion of the patients care, then you should not use the consultation codes, Cost-Blubaugh explains.

For example, if a cardiologist gets a transfer from another hospital on a patient with an MI [myocardial infarction] that should be coded as a direct admission, not a consult, she says. You may be communicating back and forth with the original physician, but that alone doesnt make it a consult [it is a referral].

The rule is: If care is transferred at the time of the initial encounter, you cannot use a consult code.

One difference between a consultation and a referral is that, when a referral is made, the referring physician doesnt expect a consultation report, she points out.

Suppose, for example, an emergency room physician sends a patient to a cardiologist for evaluation of chest pains. The ER doctor has not requested an opinion, nor does he or she expect a report from the cardiologist. He is simply turning over care to the cardiologist, she says. Hence, the patient is a referral and not a consult, and the cardiologist should code using office-visit codes for established (99211-99215) and new (99201-99205) patients.

3. Use the right categories of consult codes.

99241 - 99245 (Office or Other Outpatient Consultations) are used to report consultations for new or established patients provided in the physicians office, or in an outpatient or other ambulatory facility. This could include hospital observation services, home services, custodial care or the emergency room.

99251 - 99255 (Initial Inpatient Consultations) are used to report first consultations in acute facilities as well as nursing homes or subacute care settings. Only one initial consultation per each admission can be reported.

99261 - 99263 (Follow-Up Inpatient Consultation for established patients) are used only for inpatients. Assign a code from this category to indicate that the consultant returned to complete the work begun in the initial consultation. Or, these codes can also be used if the attending physician requests an additional evaluation.

When coding for inpatients, Theres also a lot of confusion between coding for subsequent care and transfer of care, adds Plunkett.

For example, if a primary care doctor calls in a cardiologist to give advice regarding an inpatients condition, the first time the consultant visits the inpatient unit it should be billed as an initial consultation (99251-99255). But, suppose two days later, the primary care physician calls again because something in the patients condition has changed. A follow-up consult code for the second visit should be used (99261-99263), because the consultant didnt take over the care; he or she merely gave another opinion because there had been a change in the patients condition.

Codes 99271-99275 (Confirmatory Consultation) should only be used when the patient or third-party payor asks for a second or third opinion, she points out. In the case of a third-party payor requesting an opinion, use modifier -32 (Mandated Services: Services related to mandated consultations and/or related services (eg. third-party-payor) attached to the E/M code.

4. Check documentation carefully. Documentation of the reason for the request and the response -- including the consultants opinion as well as any services ordered or performed by the consultant -- must both be in the medical record. Remember, documentation is one of the keys to being able to bill as a consult, Cost-Blubaugh stresses.

The CPT doesnt specify in what form the request and response should be. A separate written document isnt necessary. But if you are called upon for a consult by phone, both the time and date of the phone calls as well as the ensuing discussion(s) must be noted in the medical record, she adds.

5. Dont overlook same-group referrals. Will Medicare reimburse a consultation by a physician in the same group practice as the requesting physician? Yes -- if the medical necessity is documented in the patient record, and if the request for consultation is to a different subspecialist within the practice, explains Plunkett.

Realize that you may have to appeal this in order to get paid, she says. Make sure that the reason for the recommendation is specifically noted in the medical record. Indicate specifically why you need the additional opinion or advice. Dont just say Refer to Dr. X for evaluation, explains Plunket.

Consultation Criteria Example

A Medicare carrier from Ohio provided these criteria that must be present for a service to be considered a consultation:

There must be verification of two-way communication between the requesting physician and the consultant.

The patients attending physician must put the request for a consult in writing, or the medical record must contain a specific reference by the consultant to a request. The request must specify why the consultation is needed.

The medical record must contain a written consultation report by the consulting physician, as well as any services that were performed or ordered. This information must be communicated back to the requesting physician as well.

The American Medical Association states that there are three key functions a consultant performs:

Offering an opinion to the requesting physician.

Making a decision for treatment options.

Performing or ordering diagnostic tests and or therapeutic procedures.

Consulting Cardiologists Beware: Treatments During a Consult Could Trigger HCFA Audit

Initiating treatment as part of your workup without clear communication to and from the requesting physician may trigger an audit by HCFA, says Steve Arter, executive vice president in the compliance and education division, QuadraMed Corporation, a healthcare services company in Point Richmond, CA.

HCFA has a different definition of consultation than does the CPT, he explains. The CPT says that consulting physicians may initiate therapeutic treatment during the course of a consult, but Section 15506 of Medicare (HCFA) says clearly that a consultation is advice only.
HCFA does not have to go by the CPT guidelines, Arter explains.

The agency also says that if you are evaluating that patient, and then treating based on that request, you cant bill a consult. You must bill for a visit, he adds.
A consult, Arter explains, pays more than a visit because of the letter of findings that must be returned to the requesting physician. This is why a consult has a higher relative value unit (RVU), he says.

And its why HCFA auditors, hot on the trail of suspected fraud and abuse, will be keeping an eye out for consultations to see if they should have been billed as regular visits instead.

Cardiologists, for whom consultations are an integral part of a days work, need to pay special attention to documentation, Arter advises.

If you have the initial request for consulting, and then you go ahead and treat without an additional request, you could be in trouble financially, he says.

Make sure you note in the patients chart (and have the requesting physician note as well) that you asked for and received the second request to treat.

Without that paper trail, guess what? If you only have one documented contact, you do not have a consult, you have an office visit, and will be reimbursed at a lower level, he declares.

He also notes that each third-party payer may have its own interpretation of the utilization of consult codes. Get the requirements in writing from each carrier, as well as the name of the person who informed you about this policy, Arter says.

Third-party payers, who often follow Medicares lead, may also become more strict in their auditing for consultations, he warns.