Orthopedic Coding Alert

A breakdown of when you can -- and can't -- bill consults is essential for every office

Does your office bill consultations? What about in the hospital? The emergency department? Do you ever bill a consultation on a patient referred to your provider, or do you never bill consultations?

Appropriate and compliant consultation billing is a frequent cause of concern for specialists, and orthopedic physicians have their own particular concerns.

When to bill consultations (99241-99255) has been a question/problem that plagues offices everywhere. Many practices have decided not to bill consultations ever. Sometimes the decision is made based on place of service, and sometimes it is based on the diagnosis. Sometimes it is an arbitrary decision that is made across the board.

Personal experience: I have worked with orthopedic offices that have decided to never bill consultations. Their fear of failing in an audit is so great that they just stop considering a consult code when providing services to patients. In doing so, they may be sacrificing income for themselves and their practices for services provided that meet the consultation criteria. By being close-minded about it, they are losing money.

Doesn't Have to Be All or Nothing

I see the question of consultation coding as a particularly complicated choice for orthopedic practices, but the decision should not be made as an -all or nothing.- For patients whom orthopedists see, there are many instances when a consultation code is the correct service to bill because it is the service rendered and, hopefully, documented. You should examine several factors, including the consult request, and then decide whether a consultation is the most appropriate code to use.

CPT states, -A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.- Additionally, it states, -A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.-

Ask these questions: Remembering CPT's definition, when was the last time your physician was asked for his opinion and advice on a new osteoarthritis patient? Have there been occasions when your orthopedist started a patient on a therapy, and she returned to her requesting physician for continued care? Would those instances constitute a consultation or just a new patient visit? What did the documentation show? What would an auditor think? Did you make the correct coding choice?

What You Need to Qualify

If appropriately requested and documented, this visit can qualify as a consultation if your orthopedist meets the -Three R-s- of a consultation (referral from a healthcare provider, review, and report back to the referring party). Certainly, your physician would be rendering his opinion regarding the patient's knee osteoarthritis when he recommends medication, physical therapy or perhaps even a cortisone injection. Just because surgery may be the opinion or advice that he gave, the physician also had to do all the work and elements of a consultation to get to that point.

In addition, he had to perform the elements of an E/M service (history, exam and medical decision-making) and consider all options, any of the above-listed ones and others, as being possibilities.

What Medicare says: Medicare gives us the best guidance in National Coverage Provision PHYS-006 on consultations, which states that carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:

• Specifically, a consultation service is distinguished from other evaluation and management visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (such as a PA, NP, chiropractor, etc).
• The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the state in which he practices. Applicable collaboration and general supervision rules apply as well as billing rules.
• A request for a consultation 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's or qualified NPP's plan of care in the patient's medical record.
• After the consultation is provided, the consultant shall prepare a written report of his findings and recommendations, which shall be provided to the referring physician.

Review this policy to see if there are occasions when your orthopedist meets the above standards for reporting a consultation. If met (and documented) in a given situation, you could appropriately bill a consultation for that patient.

One Size Doesn't Fit All

Remember: Each situation is different. Your staff and providers must be educated to understand when you can -- and cannot -- appropriately use the consultation codes based on CPT and your payers- guidelines, such as the Medicare rules noted above. Any costs incurred to further your staff's education is money well spent and can be more than offset by the increased reimbursement from appropriately coding consultations rather than new patient visits.

There will be many situations when a consultation is not the appropriate code set to use. In fact, Medicare's policy states, -A transfer of care occurs when the patient's treating/primary/attending physician requests, in advance, that a second physician/NPP take over the responsibility for the management/treatment of an aspect of or complete care of that patient. When this occurs, the requesting physician knows the patient's problem and is not asking for an opinion or advice in this patient's management/treatment.-

What's the request? So if the call comes in asking your provider to -please take care of this fracture,- a consultation may not be the appropriate code to use. Your orthopedist would probably be -assuming care- of that problem, and this, as stated above, is not a consultation.

Whether you choose a consultation code depends on what your physician is being asked to do. Was it your orthopedist's -opinion and advice,- or was it a -transfer of care-? Make an educated choice on an individual basis, and avoid loosing revenue.

-- Jill M. Young, CPC-EDS, is the president of Young Medical Consulting LLC (www.youngmedconsult.com) in East Lansing, Mich.