Orthopedic Coding Alert

Experts reveal the answers to the 3 most commonly asked consult questions

You can get the added revenue a consultation generates without raising a red flag, as long as your orthopedist's documentation shows that a proper source requested his opinion and he notes that he's sending a report of his findings to the requesting party.
 
Because consultations (99241-99245 for outpatients, 99251-99263 for inpatients) are listed as an investigative focus area on the Office of the Inspector General's 2004 Work Plan, inappropriately coding consultation services could mean you'll risk federal audits and possible requests for paybacks.
 
"It certainly got my attention about a year ago when I was visited by two men in suits who flashed their badges at me," says Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H. "One was from the Office of Inspector General, and one was from the U.S. Department of Justice, coming to talk to me about a physician and his consultation code use." 
 
To improve your reimbursement without triggering the OIG's scrutiny, coding experts answer these three questions on reporting consultations.

Question 1: What Consult Criteria Does Medicare Require?

For a service to qualify as a consultation, the visit must fulfill the three R's - request, review and report, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions in Lakewood, N.J. In a nutshell, documentation must show that there is a request for an opinion, a review of the patient, and a report sent back to the requesting physician, according to the Medicare Carriers Manual.
 
Make sure a payer-recognized source requests your orthopedist's opinion. Some payers allow you to report a consult if a podiatrist, therapist or athletic director requests your opinion, while others will only reimburse the consultation if a physician or nurse practitioner makes the request.
 
If you don't have a valid request for an opinion, you should report a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) as long as your practice hasn't seen the patient in the last three years, Cobuzzi says. For patients your orthopedist has seen during that time, use an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Question 2: Where Should I Look for the Appropriate Documentation?

Your orthopedist must document the consultation request in the patient's medical record. For hospital inpatients and group medical practice patients, your orthopedist may note the request in the patient's common medical record.
 
In an office setting, a letter, form or note requesting the orthopedist's opinion will protect your practice if you are audited. If an attachment in the patient's medical record supports the consultation request, make sure you refer to the letter or form in the chart note, says Teresa Thompson, CPC, CCC, a national coding speaker and president of TM Consulting in Carlsborg, Wash. That way, an auditor can easily find documentation for the request.
 
If the requesting physician doesn't issue written requests, encourage your physician to document the request in the first sentence of his report, Nicoletti says. For instance, a family physician calls and asks your orthopedist to see a patient with shoulder pain. To support an outpatient consultation (99241-99245), your orthopedist should note: I am seeing this patient at Dr. Jones' request for my opinion about her shoulder pain.
 
After the patient evaluation, make sure your orthopedist documents that he reported his findings to the requesting physician. To support an outpatient consultation, your documentation must show that your orthopedist sent the requesting physician a letter describing his or her findings. Keep a copy of this letter in the patient's chart

Question 3: Do 'Request' Rules Differ for Confirmatory Consults?

According to CPT, you should report "a consultation initiated by a patient and/or family and not requested by a physician" using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient). In addition, you can report these codes when an insurer or third party seeks a second or third opinion.
 
CPT designates that you should use confirmatory consult codes when "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."
 
You can report 99271-99275 for new or established patients when the patient wants a second opinion or when an insurer requests a specialist's opinion. You can provide confirmatory consults in any setting. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code and append modifier -32 (Mandated services).