Ophthalmology and Optometry Coding Alert

Section 15506 of the Medicare Carriers Manual (MCM) specifies that three guidelines (the Three R's) must be met to bill a consultation:

1. Request: A request for a consultation, written or verbal, must be made by a physician or other appropriate source and documented in the patient's medical record (unless it is a patient-generated confirmatory consultation). Keep in mind that the request for the consultation is rendered by a physician when he or she is seeking the opinion or advice of another physician regarding the evaluation and/or management of a specific problem presented by a patient. Any physician may request a consult from any other physician and may perform a consult for his or her own patient as long as all criteria are followed. An "other appropriate source" is generally understood to mean any individual who can act on the advice/information provided by the consulting physician. According to the MCM, "Limited licensed practitioners, e.g., nurse practitioners or physician assistants, may request a consultation." A school nurse, however, may not qualify, depending on the individual carrier's guidelines. Check with the insurer if there is any doubt that an appropriate source has requested a consult. Coders and physicians should also note that the words "request" and "referral" for consultation should not be used interchangeably. Many physicians document that "the patient was referred" by another physician when they actually mean another physician requested the other physician's opinion on the condition of a patient as well as a recommended treatment plan, which constitutes a consultation.

"Our company has hired someone to come in and do their own audits every once in a while to make sure our office is compliance-compatible," which means it is imperative that terminology be kept straight and that referral not be confused with request, says Danielle Smith, CPC, coding specialist with Maine Eye Care Associates in Waterville, Maine. 2. Reason: To meet the "reason" requirement for billing consultations, you must have documentation of the request for the consultation from an appropriate source in addition to documented medical necessity supporting the consultation. According to the MCM, "In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request ... may consist of an appropriate entry in the common medical record." But in an office setting, there must be a specific written request for the consultation from the requesting physician, or the consultant's records "must show a specific reference to the request."

3. Response: After the consultation, the consultant must prepare a written report of his or her findings that is provided to the referring physician. This often includes a recommended plan of treatment or care for the patient. [...]