Optometry Coding & Billing Alert

Published on Mon Feb 13, 2006 PDF

Doctors can request consults from others in the same group.

You may have spotless documentation for the consultations your optometrist performs, but you could still lose your consult reimbursement in an audit, thanks to some new rules.
 
In Transmittal 788, dated Dec. 20, the Centers for Medicare & Medicaid Services says:

- You have to have documentation of the consult request in both the consultant's records and the requesting physician's records. The request must be part of the requesting physician's plan of care for the patient, CMS says.

- Nonphysician practitioners can perform consults, but you can't bill for the consult as a split/shared visit.

- A consult shouldn't be the same as a transfer of care, and the consultant shouldn't take over the management of the -patient's complete care for the condition.- For a transfer of care, bill the appropriate new or established patient E/M code.

- A physician can request a consult from another physician in the same group, as long as the consultant has -expertise in a specific medical area beyond the requesting professional's knowledge.-

The new requirement for the requesting physician to document the request for a consult is -a Catch 22,- says Steven Levinson, a physician in Fairfield, Conn., and 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.-
 
Wise idea: -The medical record should indicate- if the physician requests a consult, CMS official Kit Scally insisted on the Jan. 20 physician Open-Door Forum. If one physician meets another in the hallway and verbally requests a consult, they should both document that fact. But if the physician phones in the consult request to the other doctor's staff, you should document that circumstance too, she said.

Complying with CMS- new rules on consult documentation will be a challenge, but experts offer the following tips:

- Document, then consult: It's not enough for the requesting physician's file to have the consulting physician's report after the fact. The request must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, with CRN Healthcare Solutions in Tinton Falls, N.J. If your doctor performs consults, you should educate the requesting doctor's staff about this new requirement. And you may consider sending the requester ordering slips, similar to the ones radiologists and clinical labs use.

- Standardize requests: Create a form that you can fax to the requesting physician's office for documentation of the reason for the request, says Patricia Trites with Compliance Resources in Augusta, Mich. The requesting physician can keep this form in the medical record.

- Separate report: Make sure the consulting physician writes a separate report of his findings and opinion, Trites says. Send that report to the requesting physician.

In the inpatient setting, this report can go into the same medical record for the patient, but in the outpatient setting, carriers have instructed that this must be a separate record.

Learn more: Download the CMS transmittal at www.cms.hhs.gov/transmittals/downloads/R788CP.pdf.