General Surgery Coding Alert

Requesting physician must note consult in plan of care

The -Three R-s- aren't enough anymore for reporting a consult. CMS weighs in with new rules that will change document requirements for consultations.

Cautious coding experts have long recommended that both the requesting and consulting physician note the request and reason for a consultation in the patient's medical record. A recent -Medlearns Matters- article, however, now stipulates that such documentation is not merely -best practice- but absolutely required in all instances.

Docs Must Cooperate on Documentation

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].

What's the difference: 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 specify that the requesting physician had to note the request in the patient's record (see -Written Consult Request Isn't Mandatory- on page 54 of the July 2005 General Surgery Coding Alert).

Example: If one physician meets another in the hallway and verbally requests a consult, they should both document that fact, insisted 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 problem: -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 their own chart. The specialists will have to educate the requesting doctors to make sure they make notations of these consultation opinion requests in their charts 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.-

Use a Standard Sheet to Make It Easy

One way to ensure that all the 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 office of the requesting physician, Cobuzzi says. The requesting physician can fill in the necessary information and include the sheet in the patient's chart.

-You can't make the requesting physician fill out the form, but it at least increases the chances there is something in the chart,- she says. -Cooperation will be necessary if consultants are going to receive reimbursement for legitimate services they render.-

Take the lead: In cases when you are sure that a requesting physician intends for you to provide a consult, you can take the initiative to fill in all the relevant information and fax the request form directly to the requesting physician, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C.

-I-m not suggesting upcoding or -creating- a consult when none exists--but you do want to be sure that you can bill for a consult if you are providing that service. Faxing the -reverse request- form to go in the requesting physician's chart not only fulfills the documentation requirement, but if the requesting physician did not intend to send a consultation, she can simply let you know,- Dunaway says.

Free resource: See a sample consult sheet later in this issue.

An additional suggestion: The consulting physician should make a point to -return- the patient to the requesting physician, Cobuzzi says. This shows that the consult wasn't a transfer of care. Returning the patient also makes it possible for the physician to bill for another consult if the requesting physician needs another opinion for that patient in the future.

NPPs Can Provide Consultation Services

Another important guideline in Medlearn Matters article MM4215 specifies that qualified nonphysician practitioners (NPPs) can request and provide consultations (99241-99255) as long as the services are within the scope of their state license. Because rules vary from state to state, you-ll have to check your local requirements before allowing any of your NPPs to request or provide a consult service.

But NPPs cannot provide consults in the facility settings, even in collaboration with a physician, according to CMS guidelines. 

Important point: Remember, if the NPP provides a consultation, she is also designing a plan of care. This means that the NPP should report her service under her own PIN rather than -incident-to- the physician.

Same-Specialty Physicians Can Request Consults

The Medlearn Matters MM4215 article also clarifies that a physician can provide a consultation for another physician of the same specialty if the consulting physician's knowledge and expertise go above and beyond that of the requesting physician.

Use caution: Cobuzzi says, however, that -interspecialty- consultations could be an opportunity for abuse.

-It has to be clear that the physician in the group being asked for the consultation truly has a skill set that the requester does not have and that this is not being used just to get another consultation,- she says. -I think practices have to use this with care and not too often. The reason and justification better be reflected in the chart.-

Count Your R's to Get It Right

Best advice: As always, you should let documentation guide your coding. Now, more than ever, you must have a documented reason and request for the consult, along with an opinion rendered by the consulting physician, with a report sent back to the requesting physician.

Cobuzzi would also add the -fifth R- of returning (or discharging) the patient back to the requesting physician when the episode of care is complete.

One rule that never changes: If the -consulting- physician assumes full care of the patient's problem, a consult isn't appropriate, even if you meet the above requirements.

Go to the source: You can find and read Medlearn Matters article MM4215 on the CMS Web site http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf.