Gastroenterology Coding Alert

You can use a fax-back sheet to help meet new documentation requirements According to a recent Medlearn Matters article, you-ll need to be much more careful about the documentation you cite to support consultation services, and you-ll need to do it immediately.

From this point forward, CMS says both the consulting and requesting physicians must maintain written evidence of a consult. Reason and Request Must Be in Writing, Twice Starting Jan. 17, to report a consult (99241-99255), the consulting physician must receive and document a request from an appropriate source, and -the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified NPP's plan of care in the patient's medical record,- according to Medlearn Matters article MM4215 [emphasis added].

So what? These requirements--that the requesting physician must document the reason and request in the patient's plan of care--are new.

In the past, Medicare rules did not specifically state that consultation requests had to be in writing, nor did they indicate that the requesting physician had to note the request in the patient's record (see -Written Consult Request Isn't Mandatory- on page 6 of the January 2006 Gastroenterology Coding Alert).

Keep in mind: The new regulations apply only to Medicare payers.

Example: If one physician meets another in the hallway and verbally requests a consult, they should both document that fact, said CMS official Kit Scally during a Jan. 20 physician Open-Door Forum. If the physician phones in the consult request to the other doctor's staff, both practices should document that circumstance too, she said.

Potential glitch: -The request and reason have to be in both charts,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. -But the consultant only has power over his own chart. The specialists will have to educate the requesting doctors to make sure they make notations of these consultation requests so that the loop is closed.-

The new requirement for the requesting physician to document the request for a consult is -a Catch-22,- says Steven Levinson, MD, of Fairfield, Conn., author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care. -If I call the doctor who's referring me patients every six days and say, -Please send me a photocopy of your chart that shows you documented the consult,- I soon will not have any consults.- Look to a -Fax-Back- to Ease the Burden One way to ensure that all necessary documentation is in place for your office to report a consultation is to use a standard -consult sheet- that the consulting physician faxes directly to the [...]