General Surgery Coding Alert

Caution: Avoid adding a consultation to every surgical procedure.

Consultation coding is a challenge even for veteran coders. But if you know the three Rs requirement and what constitutes a transfer of care, youre well on your way to being a consultation guru. Read on to get expert answers to four of the top frequently asked consultation questions.

Question 1:What are the required components for coding a consult?

When you submit a consult claim, you should also include documentation that explains the consultation circumstances. Documentation requirements for consults vary by payer, but experts say your consult documentation should at least include evidence of:

" A written or documented request for the consult

" The consultants opinion

" Any services the consultant provides or orders

" A written report to the requesting physician or provider.

You need to be sure the visit meets the three Rs whether youre reporting a outpatient (99241-99245,Office consultation for a new or established patient &) or inpatient (99251-99255, Inpatient consultation for a new or established patient &) consultation. Every consult needs a request (in writing); a reason (again, documented in the medical record) for the consult; and a report from the consulting physician back to the requesting physician (written) that outlines findings or suggests a plan of care, says Tina Landskroener, CPC, CCS-P, PCS, business office manager for Blessing Physician Services in Quincy, Ill.. In other words, a consultation can establish a diagnosis, confirm a diagnosis, or make suggestions for treatment of the diagnosis.

Tip: Physicians in the outpatient setting can code a consultation as often as they are asked to consult. If the patient has a ongoing problem and the surgeon is asked to consult on it periodically, he can bill a consult each time the request comes in, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Childrens University Medical Group Compliance Program.

You may see this situation with a patient your surgeon is treating for melanoma, Bucknam says. Your surgeon removes the skin cancer and return the patient to their primary for follow up. However, the primary care physician finds a new lesion and asks your surgeon to consult again. You can bill another consultation for this service. However, it is important to remember that to bill higher-level consultations, all three key components -- history, exam, decision making -- are required to bill a consultation, Bucknam adds. You cant just say patient is well known to our service or something equivalent. You must document all of that history again if you want to bill a consultation.

Question 2: How important is a documented request?

A documented request is essential if youre coding a consultation. It is the request that makes a service a consultation, Bucknam says.

Even if your surgeon sees a patient and decides not to operate and sends the patient back to the requesting physician for additional care, you cannot bill a consultation if there was no request for opinion or advice.Medicare in particular is very specific about this,Bucknam warns. It is the request from one physician or other appropriate source to another physician or other appropriate consultant that establishes the service as a consultation, she stressed.

Example: If a gastroenterologist has been managing care for a patient with Crohns disease and then refers the patient to your general surgeon for an opinion regarding surgical options, you can bill a consultation (if the documentation requirements are met).

If the surgeon decides, yes, the patient should have surgery now and the patient agrees and the surgeon operates on the patient and even subsequently stays involved in the management of that condition, it is still a consultation because he as asked his opinion and he provided that opinion, Bucknam explains.

Question 3:What do payers consider a transfer of care?

This question of transfer of care often trips up coders. During a consultation, your consulting surgeon is allowed to perform diagnostic testing or even initiate treatment. However, he must return the patient to the requesting physician for ongoing care. If the surgeon instead accepts ongoing care for the patients condition,the visit doesnt meet the criteria for a consult. This would represent a transfer of care.

Remember this fact: The return does not always occur at the end of the consultative service. The consultant is permitted to initiate treatment, when appropriate, and still report a consultation, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

When the consultant completes the course of treatment, eventually discharging the patient from his care, a notation in the medical record helps distinguish between ongoing care and future consultation requests, Pohlig explains.

How it works: In the example above of the patient with Crohns disease, consider if an internal medicine doctor is managing the patients care and that physician reaches a point where she feels the patients disease isoutside the scope of her practice and sends the patient to a surgeon to evaluate and treat the condition. This would be a transfer of care, even if the surgeon decides not to operate and sends the patient back to her referring physician or on to another provider, Bucknam says.

Question 4: Does every surgery involve an inpatient consultation?

Another surgeon may request a consultation from your surgeon prior to performing surgery on a patient. The visit must still meet all the requirements of a consultation,however, Landskroener says. Keep in mind that the request should not simply be for a routine screening such as screening colonoscopy.

You should only bill for a consultation if the primary physician caring for the inpatient requested a consultation from your surgeon. In other words, only bill a consultation if the primary physician requested your doctors opinion or advice for a treatment plan for a specific condition.

If your physician was called in just to perform a surgery, and there was no request for an opinion or recommendation, then you cannot bill a consult. But keep in mind that a consultant can lead to treatment once the physician completes his consultation.

You would bill a consult only if the primary doc requested of your doc an opinion and/or recommendation on a specific condition, confirms Tracy Helget, CPC,billing office supervisor for Medical Associates of Manhattan PA in Manhattan, Kan. If your doc was requested to perform a surgery, there was no request for an opinion or recommendation, therefore no consult. It all depends on how services are documented.

Note: A separate report sent to the requesting physician is not required when the requesting physician and consultant share a common medical record (which always occurs in the inpatient setting).

If the service does qualify for a consultation code, bill an inpatient consultation using the most appropriate choice from 99251-99255 (Inpatient consultation for a new or established patient &), depending on the level of service.