Orthopedic Coding Alert

Check out Medicare's consult request regs before you bill a consult

Orthopedic coders have known for years that consultations require a request from another clinician, but this year Medicare makes it clear that you must document that request in writing, finally ending speculation about whether you can report the consult codes based on verbal requests.

If you want to continue to collect for your orthopedic surgeon's consultation services (99241-99255), make sure you follow CMS- new rules to the letter.

Get Request--and Reason--in Writing

On Dec. 20, 2005, CMS released Transmittal 788, which states, -A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record.-

The Transmittal does give some slight wiggle room about when the written request can take place and states that the initial request may be a verbal interaction between the requesting physician and the consulting physician. However, both physicians should document the verbal conversation in the patient's medical record.
 
The Proof Is in the Details of Your Documentation

Even if both physicians document the request in writing, without a documented reason for the consultation, you won't see any money for your orthopedist's service. Make sure the requesting physician specifies in the original consultation request why the patient needs the service before you report a consultation code.

In the past, your physician may have simply written -orthopedic consult- at the top of his consult note when he performed a consultation at another physician's request. Instead, under the new guidelines, the surgeon should write something like -orthopedic consult per internist's request- and include the reason for the internist's request.
 
The medical record should indicate if the physician requests a consult, CMS official Kit Scally said during the Jan. 20 physician Open-Door Forum. If an orthopedic surgeon meets another physician in the hallway and verbally requests a consult, both physicians should document that fact. If one physician phones in the consult request to the other physician's staff, you should document that circumstance too, Scally said.

Capture All the Details With a Standard Form

CMS has also made it clear that your surgeon, as the consulting physician, must maintain a documented request in the patient's medical record, but the requesting physician now also has to include the request in the patient's medical record.

You can't simply make sure the requesting physician's file has the consulting physician's report after the fact. The request for the opinion must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J.

Tip: You may consider using ordering slips when your physician requests a consult, and asking for a written request when a physician sends a patient to you for consultation. If a colleague regularly sends patients to your office, you should give the requester ordering slips, similar to the ones radiologists and clinical labs use.

You can fax a form to the requesting physician's office, says Patricia Trites, MPA, CHBC, CPC, CHCC, CHCO, CEO of Healthcare Compliance Resources in Augusta, Mich.

The requesting physician can keep this form in the medical record, which solves your documentation problems and also helps you indicate the reason for the consultation request.

See our clip-and-save, -This Tool Can Make Your Consult Documentation Complete,- on page 30 for a sample fax request form.

Avoid Unnecessary Pre-Op Clearance Requests

Because you have to provide a specific reason for the consultation, you won't be able to report presurgical clearance visits that aren't medically necessary as consultations, coding experts say.

When your orthopedic surgeon plans surgery for a patient, he might get a medical consultation from another physician as a preventive measure due to hospital guidelines or often just out of good general medical practice.
 In the past, the documentation for the consultation might have said, -surgical clearance.- Now if your orthopedic surgeon doesn't identify some specific reason that the patient needs that surgical clearance, payers will consider it a screening, not a consultation.

Example: Your orthopedic surgeon refers a patient to an internist for medical clearance before a meniscectomy. Your surgeon must have a documented medical reason, such as a heart condition, hypertension or diabetes, for why he wants the internist to clear the patient for surgery.